Healthcare Provider Details

I. General information

NPI: 1497680656
Provider Name (Legal Business Name): FIVE LAKES DENTAL STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 DOWNTOWN PLZ
FAIRMONT MN
56031-1702
US

IV. Provider business mailing address

31 DOWNTOWN PLZ
FAIRMONT MN
56031-1702
US

V. Phone/Fax

Practice location:
  • Phone: 507-235-9040
  • Fax:
Mailing address:
  • Phone: 507-235-9040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number
License Number State

VIII. Authorized Official

Name: JEREMY JOSEPH STAUFFER
Title or Position: OWNER/CERAMIST
Credential: CDT
Phone: 507-235-9040