Provider Demographics
NPI:1306258371
Name:LAKES REGION DENTAL CENTER, LLC
Entity type:Organization
Organization Name:LAKES REGION DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-624-1648
Mailing Address - Street 1:183 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-1888
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 CENTER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:ME
Practice Address - Zip Code:04963-4927
Practice Address - Country:US
Practice Address - Phone:207-624-1648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME4188261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental