Basic Information
| Provider Information | |||||||||
| NPI: | 1376143081 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE CITY DENTAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 999 | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812350999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709442331 | ||||||||
| FaxNumber: | 9709442320 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 N HENSON ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812355134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709442331 | ||||||||
| FaxNumber: | 9709442320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2020 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHIDDON | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9709442331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 9000141620 | 05 | CO | MEDICAID |