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General NPI Number Information
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NPI Number | 1457757288
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Entity Type | Organization
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Legal Business Name | LAKE COUNTRY EYE CARE, LLC
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Dates
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Enumeration Date | 11/05/2014
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Last Update Date | 06/30/2015
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Provider Practice Location Address
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Address Line | 520 HARTBROOK DR STE F
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City | HARTLAND
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State | WI
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Zip | 53029-1402
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Country | US
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Telephone | 262-367-6610
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Fax | 262-367-0964
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Provider Business Mailing Address
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Address Line | 520 HARTBROOK DR STE F
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City | HARTLAND
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State | WI
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Zip | 53029-1402
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Country | US
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Telephone | 262-367-6610
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Fax | 262-367-0964
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Authorized Official
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Title or Position | OPTOMETRIST/OWNER
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Name | DR. AMBER A DENTZ
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Credential | O.D.
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Telephone | 262-367-6610
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2878-035
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License Number State | WI
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