Provider Demographics
NPI:1356462733
Name:LAKE, RYAN J (DMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:J
Last Name:LAKE
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 1:246 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1537
Mailing Address - Country:US
Mailing Address - Phone:732-381-8231
Mailing Address - Fax:732-381-8056
Practice Address - Street 1:246 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1537
Practice Address - Country:US
Practice Address - Phone:732-381-8231
Practice Address - Fax:732-381-8056
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI019573001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice