Provider Demographics
NPI:1124064803
Name:LAKE, STEPHANIE LOUISE (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LOUISE
Last Name:LAKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 N 179TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-2267
Mailing Address - Country:US
Mailing Address - Phone:492-733-1325
Mailing Address - Fax:
Practice Address - Street 1:17110 LAKESIDE HILLS PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-5600
Practice Address - Country:US
Practice Address - Phone:402-718-8737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist