Healthcare Provider Details

I. General information

NPI: 1891669727
Provider Name (Legal Business Name): MATTHEW B LAKE, DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 COUNTRY CLUB RD
EUGENE OR
97401-6008
US

IV. Provider business mailing address

721 COUNTRY CLUB RD
EUGENE OR
97401-6008
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-1199
  • Fax: 541-686-3033
Mailing address:
  • Phone: 541-686-1199
  • Fax: 541-686-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MATTHEW BRYANT LAKE
Title or Position: PRACTICE OWNER
Credential: DMD
Phone: 541-686-1199