Provider Demographics
NPI:1528134509
Name:LAKE, RANDOLPH LEWIS (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:LEWIS
Last Name:LAKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 NE SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-3335
Mailing Address - Country:US
Mailing Address - Phone:425-228-2555
Mailing Address - Fax:425-228-0220
Practice Address - Street 1:3200 NE SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-3335
Practice Address - Country:US
Practice Address - Phone:425-228-2555
Practice Address - Fax:425-228-0220
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000052821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice