| NPI | 1710477732 |
|---|---|
| Doing Business As | LAKE AVENUE DENTAL |
| Entity Type | Organization |
| Authorized Contact | CASSANDRA PETERSEN Credentialing Team Lead 217-540-8972 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2018-05-15 |
| Last Update Date | 2018-05-15 |