# CORDELL LAKE, D.D.S., LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1619446077
- **Authorized official:** CORDELL LAKE DDS (GENERAL DENTIST)
- **Authorized official phone:** (816) 728-1630

## Contact information

- **Practice address:** 12 E HARRISON ST, FARMINGTON, MO 63640-1859
- **Practice address phone:** (573) 756-4344
- **Mailing address:** 3145 CROSS CREEK DR, CAMDENTON, MO 65020-9377
- **Mailing address phone:** (816) 728-1630

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 11/15/2018
- **Last updated:** 11/15/2018