Provider Demographics
NPI:1962871608
Name:LAKES DERMATOLOGY, PA
Entity type:Organization
Organization Name:LAKES DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REHANA
Authorized Official - Middle Name:LEILA
Authorized Official - Last Name:AHMED-SAUCEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:612-387-4627
Mailing Address - Street 1:2732 IRVING AVE S
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1049
Mailing Address - Country:US
Mailing Address - Phone:612-387-4627
Mailing Address - Fax:612-377-9713
Practice Address - Street 1:14305 SOUTHCROSS DR W
Practice Address - Street 2:SUITE 110
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-7009
Practice Address - Country:US
Practice Address - Phone:612-387-4627
Practice Address - Fax:612-377-9713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51837207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty