Provider Demographics
NPI:1699959528
Name:LAKE DENTISTRY LLC
Entity type:Organization
Organization Name:LAKE DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:ROBERTS
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-874-2243
Mailing Address - Street 1:735 HARRY C. RAYSOR DRIVE
Mailing Address - Street 2:P.O. BOX 237
Mailing Address - City:ST. MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-0237
Mailing Address - Country:US
Mailing Address - Phone:803-874-2243
Mailing Address - Fax:
Practice Address - Street 1:735 HARRY C. RAYSOR DRIVE
Practice Address - Street 2:
Practice Address - City:ST. MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-0237
Practice Address - Country:US
Practice Address - Phone:803-874-2243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC02808122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty