Provider Demographics
NPI:1215793401
Name:LAKELAND DENTISTS, P.L.L.C.
Entity type:Organization
Organization Name:LAKELAND DENTISTS, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-280-0466
Mailing Address - Street 1:31508 291ST AVE
Mailing Address - Street 2:
Mailing Address - City:BROWERVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56438-4901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3042
Practice Address - Country:US
Practice Address - Phone:320-280-0466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental