Provider Demographics
NPI:1538328059
Name:LAKELAND FAMILY DENTAL
Entity type:Organization
Organization Name:LAKELAND FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FU
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-424-4415
Mailing Address - Street 1:106 BROADWAY ST EAST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-9351
Mailing Address - Country:US
Mailing Address - Phone:763-295-3036
Mailing Address - Fax:763-295-4514
Practice Address - Street 1:106 BROADWAY STREET EAST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362
Practice Address - Country:US
Practice Address - Phone:763-295-3036
Practice Address - Fax:763-295-4514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FU WONG DDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-09
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10739122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty