Provider Demographics
NPI:1336418458
Name:LAKE, CHARLEEN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLEEN
Middle Name:J
Last Name:LAKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 N ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3127
Mailing Address - Country:US
Mailing Address - Phone:630-323-4971
Mailing Address - Fax:
Practice Address - Street 1:321 N ADAMS ST
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3127
Practice Address - Country:US
Practice Address - Phone:630-323-4971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190165781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice