Provider Demographics
NPI:1063942456
Name:LAKE, MATTHEW JOSEPH (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:LAKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 S HARRISON ST STE 1400
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-3937
Mailing Address - Country:US
Mailing Address - Phone:303-285-6098
Mailing Address - Fax:
Practice Address - Street 1:390 S WILCOX ST STE A
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1951
Practice Address - Country:US
Practice Address - Phone:303-660-6000
Practice Address - Fax:303-660-9745
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2032081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice