Provider Demographics
NPI:1750952750
Name:LAKE, MATTHEW BRYANT (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BRYANT
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 1:201 SE WASHINGTON ST STE B
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-2860
Mailing Address - Country:US
Mailing Address - Phone:503-623-2666
Mailing Address - Fax:
Practice Address - Street 1:201 SE WASHINGTON ST STE B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2860
Practice Address - Country:US
Practice Address - Phone:503-623-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC123721223G0001X
ORD117461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice