Provider Demographics
NPI:1457514259
Name:LAKE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:LAKE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-348-9888
Mailing Address - Street 1:1037 PALISADES BLVD STE 9
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3340
Mailing Address - Country:US
Mailing Address - Phone:573-348-9888
Mailing Address - Fax:573-348-9894
Practice Address - Street 1:1037 PALISADES BLVD STE 9
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065
Practice Address - Country:US
Practice Address - Phone:573-348-9888
Practice Address - Fax:573-348-9894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060147071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty