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General NPI Number Information
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NPI Number | 1669585402
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Entity Type | Organization
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Legal Business Name | R L LAKE DDS INC
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Dates
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Enumeration Date | 08/16/2006
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Last Update Date | 09/19/2007
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Provider Practice Location Address
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Address Line | 200 DALLAS ST
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City | TALIHINA
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State | OK
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Zip | 74571-2402
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Country | US
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Telephone | 918-567-3961
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Fax | 918-567-3424
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Provider Business Mailing Address
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Address Line | 200 DALLAS ST
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City | TALIHINA
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State | OK
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Zip | 74571-2402
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Country | US
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Telephone | 918-567-3961
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Fax | 918-567-3424
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Authorized Official
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Title or Position | PRESIDENT R L LAKE DDS INC
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Name | DR. RAMON L LAKE JR.
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Credential | DDS
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Telephone | 918-567-3961
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4059
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License Number State | OK
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