| NPI | 1942941117 |
|---|---|
| Doing Business As | LAKE RIDGE DENTAL CARE |
| Entity Type | Organization |
| Authorized Contact | HILLARY THULL Credentialing Coordinator 217-540-8946 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2022-04-04 |
| Last Update Date | 2022-04-04 |