Provider Demographics
NPI:1215263017
Name:LAKE, JOHN CAMPBELL JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CAMPBELL
Last Name:LAKE
Suffix:JR
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 1:2706 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-4004
Mailing Address - Country:US
Mailing Address - Phone:803-276-2090
Mailing Address - Fax:
Practice Address - Street 1:2706 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-4004
Practice Address - Country:US
Practice Address - Phone:803-276-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC45931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4593Medicaid