| Lake Dental Group | |
|
400 Lake Ave Racine WI 53403-1020 | |
| (262) 633-0775 | |
| Not Available |
| Full Name | Lake Dental Group |
|---|---|
| Speciality | Dentist |
| Location | 400 Lake Ave, Racine, Wisconsin |
| Authorized Official Name and Position | Lilly Poole (OFFICE MANAGER) |
| Authorized Official Contact | 2626330775 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Lake Dental Group 400 Lake Ave Racine WI 53403-1020 Ph: (262) 633-0775 | Lake Dental Group 400 Lake Ave Racine WI 53403-1020 Ph: (262) 633-0775 |
| NPI Number | 1922314210 |
|---|---|
| Provider Enumeration Date | 08/24/2010 |
| Last Update Date | 08/24/2010 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922314210 | NPI | - | NPPES |
| 33605400 | Medicaid | WI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | (* (Not Available)) | Primary |
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