MEDICARE: DENNIS LAKE M.D.

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	208000000X	Pediatrics Physician	4301039973	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700986205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS LAKE M.D.

Provider Business Mailing Address
First Line	:	710 KENMOOR AVE SE
Second Line	:	SUITE 110
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2379
Country	:	US
Telephone Number	:	616-949-6112
Fax Number	:	616-949-8530

Provider Business Practice Location Address
First Line	:	710 KENMOOR AVE SE
Second Line	:	SUITE 110
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2379
Country	:	US
Telephone Number	:	616-949-6112
Fax Number	:	616-949-8530

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

Provider Enumeration Date	:	09/24/2006
Last Update Date	:	07/08/2007

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Directions to “ DENNIS LAKE M.D.” Practice Location

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