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NPI Code Detail

MEDICARE: DR. JEREMY BRIAN LAKE DDS

MEDICARE: DR. JEREMY BRIAN LAKE DDS
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
11223G0001XGeneral Practice Dentistry3792WV

General Provider Information

NPI Number : 1891981189
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JEREMY BRIAN LAKE DDS
Provider Business Mailing Address
First Line : 724 LELEMANU ALY
Second Line :
City : HONOLULU
State : HI
Zip : 96818-5942
Country : US
Telephone Number : 707-392-9419
Fax Number :
Provider Business Practice Location Address
First Line : 755 SCOTT CIR BLDG 559
Second Line :
City : JBPHH
State : HI
Zip : 96853-5399
Country : US
Telephone Number : 808-448-6371
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/20/2007
Last Update Date : 08/26/2022

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