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General NPI Number Information
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NPI Number | 1659861599
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Entity Type | Organization
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Legal Business Name | JAMES LAKE DDS INC
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Dates
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Enumeration Date | 05/16/2018
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Last Update Date | 05/16/2018
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Provider Practice Location Address
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Address Line | 57340 29 PALMS HWY
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City | YUCCA VALLEY
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State | CA
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Zip | 92284-2927
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Country | US
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Telephone | 760-365-0774
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Fax | 760-365-3995
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Provider Business Mailing Address
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Address Line | 57340 29 PALMS HWY
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City | YUCCA VALLEY
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State | CA
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Zip | 92284-2927
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Country | US
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Telephone | 760-365-0774
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Fax | 760-365-3995
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAMES ALAN LAKE
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Credential | DDS
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Telephone | 760-365-0774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 59657
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License Number State | CA
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