Provider Demographics
NPI:1528235314
Name:LAKE GROVE DENTAL
Entity type:Organization
Organization Name:LAKE GROVE DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:GW
Authorized Official - Last Name:MAURER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-636-3641
Mailing Address - Street 1:4055 MERCANTILE DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2633
Mailing Address - Country:US
Mailing Address - Phone:503-636-3641
Mailing Address - Fax:503-765-5310
Practice Address - Street 1:4055 MERCANTILE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2633
Practice Address - Country:US
Practice Address - Phone:503-636-3641
Practice Address - Fax:503-765-5310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty