Provider Demographics
NPI:1518418243
Name:LAKELAND FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:LAKELAND FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-705-9076
Mailing Address - Street 1:910 OCONOMOWOC PKWY
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 N SUMMIT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4467
Practice Address - Country:US
Practice Address - Phone:262-567-1323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6544-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty