MEDICARE: CENTRAL LAKES COMMUNITY DENTAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0001X	Public Health Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467508226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL LAKES COMMUNITY DENTAL CLINIC

Provider Business Mailing Address
First Line	:	3200 LABORE RD.
Second Line	:	SUITE 104
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-5186
Country	:	US
Telephone Number	:	651-539-7200
Fax Number	:

Provider Business Practice Location Address
First Line	:	11600 STATE AVE.
Second Line	:	SUITE A
City	:	BRAINERD
State	:	MN
Zip	:	56401
Country	:	US
Telephone Number	:	218-855-8600
Fax Number	:	651-431-7355

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	LYNN GLANCEY
Credential	:
Telephone Number	:	651-539-7200

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	01/07/2026

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Directions to “CENTRAL LAKES COMMUNITY DENTAL CLINIC ” Practice Location

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