Provider Demographics
NPI:1295303378
Name:LACKE, AUSTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:
Last Name:LACKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1852 FREDERICKSBURG LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60503-3647
Mailing Address - Country:US
Mailing Address - Phone:630-200-9222
Mailing Address - Fax:
Practice Address - Street 1:3027 ENGLISH ROWS AVE STE 203
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-5107
Practice Address - Country:US
Practice Address - Phone:630-904-1106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019033069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist