Provider Demographics
NPI:1053558049
Name:LAKE COUNTRY DENTAL CARE PC
Entity type:Organization
Organization Name:LAKE COUNTRY DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEFKOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-452-3768
Mailing Address - Street 1:750 N COBB ST
Mailing Address - Street 2:STE. 140
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2390
Mailing Address - Country:US
Mailing Address - Phone:478-452-3768
Mailing Address - Fax:478-452-2704
Practice Address - Street 1:750 N COBB ST
Practice Address - Street 2:STE. 140
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2390
Practice Address - Country:US
Practice Address - Phone:478-452-3768
Practice Address - Fax:478-452-2704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty