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1598627820 NPI number — BLUE LAKE SMILES

NPI Number: 1598627820
Health Care Provider/Practitioner: BLUE LAKE SMILES

Information about “1598627820” NPI (BLUE LAKE SMILES) exists in 1598627820 in HTML format HTML  |  1598627820 in plain Text format TXT  |  1598627820 in PDF (Portable Document Format) PDF  |  1598627820 in an XML format XML  formats.

NPI Number : 1598627820 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1598627820",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "BLUE LAKE SMILES",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "10749 N TREE SPARROW DR",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "MEQUON",
    "MailingAddressStateName": "WI",
    "MailingAddressPostalCode": "53097",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "612-308-2244",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "845 S MAIN ST STE 130",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "FOND DU LAC",
    "PracticeLocationAddressStateName": "WI",
    "PracticeLocationAddressPostalCode": "54935-6116",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "920-581-8505",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "11/25/2025",
    "LastUpdateDate": "11/25/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "JAIN",
    "AuthorizedOfficialFirstName": "GAURAV",
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": "PEDIATRIC DENTIST",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "DDS",
    "AuthorizedOfficialTelephoneNumber": "612-308-2244",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "1223P0221X",
        "TaxonomyName": "Pediatric Dentistry",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY  GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
      }
    }
  }
}
                
            

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