MEDICARE: LAKE EOLA DENTAL, INC.

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	122300000X	Dentist

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	:	1770003782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE EOLA DENTAL, INC.

Provider Business Mailing Address
First Line	:	338 N MAGNOLIA AVE STE C
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32801-1639
Country	:	US
Telephone Number	:	407-930-7007
Fax Number	:

Provider Business Practice Location Address
First Line	:	338 N MAGNOLIA AVE STE C
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32801-1639
Country	:	US
Telephone Number	:	407-930-7007
Fax Number	:	407-930-5410

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HOANG HO
Credential	:	DMD
Telephone Number	:	804-687-2817

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	08/17/2022

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Directions to “LAKE EOLA DENTAL, INC. ” Practice Location

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