Provider First Line Business Practice Location Address:
956 WEST BROADWAY
Provider Second Line Business Practice Location Address:
LAKES DENTAL CLINIC
Provider Business Practice Location Address City Name:
FOREST LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-464-7277
Provider Business Practice Location Address Fax Number:
651-464-6857
Provider Enumeration Date:
12/06/2006