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General NPI Number Information
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NPI Number | 1598627820
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Entity Type | Organization
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Legal Business Name | BLUE LAKE SMILES
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Dates
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Enumeration Date | 11/25/2025
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Last Update Date | 11/25/2025
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Provider Practice Location Address
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Address Line | 845 S MAIN ST STE 130
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City | FOND DU LAC
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State | WI
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Zip | 54935-6116
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Country | US
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Telephone | 920-581-8505
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Fax |
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Provider Business Mailing Address
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Address Line | 10749 N TREE SPARROW DR
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City | MEQUON
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State | WI
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Zip | 53097
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Country | US
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Telephone | 612-308-2244
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | GAURAV JAIN
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Credential | DDS
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Telephone | 612-308-2244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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