Provider Demographics
NPI:1790659746
Name:LAKELAND FAMILY DENTAL LLC
Entity type:Organization
Organization Name:LAKELAND FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-687-4455
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-1030
Mailing Address - Country:US
Mailing Address - Phone:208-687-4455
Mailing Address - Fax:208-687-4456
Practice Address - Street 1:14596 N HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-8682
Practice Address - Country:US
Practice Address - Phone:208-687-4455
Practice Address - Fax:208-687-4456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty