1255444634 NPI number — LAKE DENTAL SERVICES, P.A.

Table of content: (NPI 1255444634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255444634 NPI number — LAKE DENTAL SERVICES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE DENTAL SERVICES, P.A.
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:
1255444634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13195 SW 134 ST
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-274-2499
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
820 STATE RD. 434 N.
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ALTAMONTE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-865-9100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER RELATIONS
Authorized Official Telephone Number:
305-274-2499

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 105479300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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