MEDICARE: DR. VALERIE E LAKE D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12010452A	IN

General Provider Information

NPI Number	:	1114048121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VALERIE E LAKE D.D.S.

Provider Business Mailing Address
First Line	:	6211 COVINGTON RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7311
Country	:	US
Telephone Number	:	260-432-1579
Fax Number	:	260-432-4540

Provider Business Practice Location Address
First Line	:	6211 COVINGTON RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7311
Country	:	US
Telephone Number	:	260-432-1579
Fax Number	:	260-432-4540

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	11/08/2021

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