Provider Demographics
NPI:1396991196
Name:LAKE FOREST DENTAL ASSOCIATES, PC
Entity type:Organization
Organization Name:LAKE FOREST DENTAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:COTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-234-6440
Mailing Address - Street 1:133 E LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1205
Mailing Address - Country:US
Mailing Address - Phone:847-234-6440
Mailing Address - Fax:847-234-2195
Practice Address - Street 1:133 E LAUREL AVE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1205
Practice Address - Country:US
Practice Address - Phone:847-234-6440
Practice Address - Fax:847-234-2195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0148221223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty