Provider Demographics
NPI:1801087531
Name:LASK, MICHAEL DONALD (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DONALD
Last Name:LASK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 W ORCHARD ST
Mailing Address - Street 2:A
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1234
Mailing Address - Country:US
Mailing Address - Phone:618-283-2929
Mailing Address - Fax:
Practice Address - Street 1:607 W ORCHARD ST
Practice Address - Street 2:A
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1234
Practice Address - Country:US
Practice Address - Phone:618-283-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice