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General NPI Number Information
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NPI Number | 1265248173
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Entity Type | Organization
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Legal Business Name | LAKE AREA DENTAL
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Dates
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Enumeration Date | 12/05/2024
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Last Update Date | 12/05/2024
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Provider Practice Location Address
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Address Line | 4801 HIGHWAY 61 N STE 301
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City | WHITE BEAR LAKE
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State | MN
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Zip | 55110-2753
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Country | US
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Telephone | 651-762-8474
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Fax |
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Provider Business Mailing Address
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Address Line | 140 WILDWOOD CT
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City | MAHTOMEDI
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State | MN
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Zip | 55115-4200
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Country | US
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Telephone | 651-308-1177
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | JORDAN DITTBERNER
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Credential | DDS
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Telephone | 651-308-1177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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