1801196134 NPI number — LAKE DENTAL OF SARATOGA, PC

Table of content: (NPI 1801196134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801196134 NPI number — LAKE DENTAL OF SARATOGA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE DENTAL OF SARATOGA, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801196134
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
176 LAKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARATOGA SPRINGS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12866-2529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-935-0068
Provider Business Mailing Address Fax Number:
518-581-1145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
176 LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARATOGA SPRINGS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12866-2529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-935-0068
Provider Business Practice Location Address Fax Number:
518-581-1145
Provider Enumeration Date:
11/03/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DENNIS
Authorized Official First Name:
TRACIE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
BOOK KEEPER
Authorized Official Telephone Number:
518-817-2490

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  052845 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 022051-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1710943774 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1467654178 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".