Provider Demographics
NPI:1902227036
Name:TRUMAN LAKE DENTAL, LLC
Entity type:Organization
Organization Name:TRUMAN LAKE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LANCASTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:660-438-5139
Mailing Address - Street 1:1631 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355-3060
Mailing Address - Country:US
Mailing Address - Phone:660-438-5139
Mailing Address - Fax:660-438-8649
Practice Address - Street 1:1631 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:MO
Practice Address - Zip Code:65355-3060
Practice Address - Country:US
Practice Address - Phone:660-438-5139
Practice Address - Fax:660-438-8649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120185601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty