Provider Demographics
NPI:1992403919
Name:LAKEVILLE MODERN DENTISTRY, PLLC
Entity type:Organization
Organization Name:LAKEVILLE MODERN DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:920-723-8420
Mailing Address - Street 1:17746 KENWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9454
Mailing Address - Country:US
Mailing Address - Phone:952-388-1778
Mailing Address - Fax:952-388-1763
Practice Address - Street 1:17746 KENWOOD TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9454
Practice Address - Country:US
Practice Address - Phone:920-723-8420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-20
Last Update Date:2023-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1194394288OtherNPI TYPE I