Provider Demographics
NPI:1174529903
Name:LAKE, TERRY L (DMD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:L
Last Name:LAKE
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 1:5001 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1217
Mailing Address - Country:US
Mailing Address - Phone:304-768-5721
Mailing Address - Fax:304-768-6131
Practice Address - Street 1:5001 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1217
Practice Address - Country:US
Practice Address - Phone:304-768-5721
Practice Address - Fax:304-768-6131
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2379WV1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice