Healthcare Provider Details

I. General information

NPI: 1417329988
Provider Name (Legal Business Name): LAKEHAVEN DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

758 HWY 28
LANGLEY OK
74350-0339
US

IV. Provider business mailing address

PO BOX 339
LANGLEY OK
74350-0339
US

V. Phone/Fax

Practice location:
  • Phone: 918-782-9744
  • Fax:
Mailing address:
  • Phone: 918-782-9744
  • Fax:

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 HACKER
Title or Position: PRESIDENT
Credential:
Phone: 918-787-7900