Healthcare Provider Details

I. General information

NPI: 1821187683
Provider Name (Legal Business Name): ULRICH LAKE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVER PLACE STE 110
MADISON WI
53716
US

IV. Provider business mailing address

100 RIVER PLACE STE 110
MADISON WI
53716
US

V. Phone/Fax

Practice location:
  • Phone: 608-222-6160
  • Fax: 608-222-6248
Mailing address:
  • Phone: 608-222-6160
  • Fax: 608-222-6248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4288015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: