Organization

Lake Street Dental

Legal Business Name

Lake Street Dental

NPI Number

1184829509

NPI Type

Organization

Enumeration Date

06/16/2007

Specialties

(Taxonomies)

Code

1223G0001X
1223P0300X
1223P0700X

Primary Taxonomy

No
No
No

Licenses

State

Minnesota
Minnesota
Minnesota

License Number

D11889
D11718
D12007

Contact
Information

Purpose

Mailing
Location

Address

1508 E LAKE ST
1508 E LAKE ST

City

Minneapolis
Minneapolis

State

MN
MN

Postal Code

55407-1720
55407-1720

Country

US
US

Telephone Number

(612) 724-1717
(612) 724-1717

Authorized Official

Name

Renee Good

Title or Position

PERIOSONTIST

Telephone Number

(612) 724-1717

Provider data last refreshed from NPPES NPI registry on 11/19/2024

Data last updated by provider on 08/22/2020

Provider Address