# BLUE LAKE SMILES

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Blue Lake Smiles Pediatric Dentistry
- **Organization subpart:** No

## Provider details

- **NPI number:** 1598627820
- **Authorized official:** GAURAV JAIN DDS (PEDIATRIC DENTIST)
- **Authorized official phone:** (612) 308-2244

## Contact information

- **Practice address:** 845 S MAIN ST STE 130, FOND DU LAC, WI 54935-6116
- **Practice address phone:** (920) 581-8505
- **Mailing address:** 10749 N TREE SPARROW DR, MEQUON, WI 53097
- **Mailing address phone:** (612) 308-2244

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | — | NULL | Yes |
| 1223P0221X | Pediatric Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 11/25/2025
- **Last updated:** 11/25/2025