Healthcare Provider Details

I. General information

NPI: 1255444634
Provider Name (Legal Business Name): LAKE DENTAL SERVICES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 STATE RD. 434 N. SUITE B
ALTAMONTE SPRINGS FL
32714
US

IV. Provider business mailing address

13195 SW 134 ST 2ND FLOOR
MIAMI FL
33186
US

V. Phone/Fax

Practice location:
  • Phone: 407-865-9100
  • Fax:
Mailing address:
  • Phone: 305-274-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GOMEZ
Title or Position: PROVIDER RELATIONS
Credential:
Phone: 305-274-2499