Provider Demographics
NPI:1306968003
Name:LAKE, SAMUEL LYON (DDS, MSD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LYON
Last Name:LAKE
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14420 BEL RED RD STE 105
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3930
Mailing Address - Country:US
Mailing Address - Phone:425-641-4200
Mailing Address - Fax:425-641-4418
Practice Address - Street 1:14420 BEL RED RD STE 105
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3930
Practice Address - Country:US
Practice Address - Phone:425-641-4200
Practice Address - Fax:425-641-4418
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA52831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics