Healthcare Provider Details

I. General information

NPI: 1558361667
Provider Name (Legal Business Name): LAKE COUNTY DENTAL LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 JAMES ST
BRAINERD MN
56401-2965
US

IV. Provider business mailing address

402 JAMES ST
BRAINERD MN
56401-2965
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-4243
  • Fax: 218-825-8102
Mailing address:
  • Phone: 218-829-4243
  • Fax: 218-825-8102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberMATTSON 10813
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberMOEN 9531
License Number StateMN

VIII. Authorized Official

Name: JEFFREY JOHN MATTSON
Title or Position: OWNER
Credential: DDS
Phone: 218-829-4243