Healthcare Provider Details

I. General information

NPI: 1215152608
Provider Name (Legal Business Name): LAKEHAVEN DENTAL P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 3RD STREET
GROVE OK
74344
US

IV. Provider business mailing address

PO BOX 451897
GROVE OK
74345-1897
US

V. Phone/Fax

Practice location:
  • Phone: 918-787-7900
  • Fax: 918-787-5871
Mailing address:
  • Phone: 918-787-7900
  • Fax: 918-787-5871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: STEFAN S HACKER
Title or Position: PRESIDENT
Credential: DDS
Phone: 918-787-7900