Provider Demographics
NPI:1215152608
Name:LAKEHAVEN DENTAL P.C
Entity type:Organization
Organization Name:LAKEHAVEN DENTAL P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEFAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:HACKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-787-7900
Mailing Address - Street 1:PO BOX 451897
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-1897
Mailing Address - Country:US
Mailing Address - Phone:918-787-7900
Mailing Address - Fax:918-787-5871
Practice Address - Street 1:200 E 3RD STREET
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:918-787-7900
Practice Address - Fax:918-787-5871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200253590AMedicaid