Active NPI
Kevin Joseph Lake, DMD
- Dentist
- New Providence, NJ
National Provider Identifier
1083638399
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 22DI02044100
- Practice address
- 5 Ethan Dr
New Providence, NJ 07974-1604 - Phone
- (908) 464-5270
- NPI assigned
- Jul 27, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 22DI02044100 | NJ | Primary |
Addresses
Primary practice location
5 Ethan Dr
New Providence, NJ 07974-1604
Mailing address
5 Ethan Dr
New Providence, NJ 07974-1604
Phone (908) 464-5270
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Apr 19, 2016 through Apr 19, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 22DI02044100 | NJ | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153958400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1083638399",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5 ETHAN DR",
"city": "NEW PROVIDENCE",
"state": "NJ",
"postal_code": "079741604",
"telephone_number": "908-464-5270"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5 ETHAN DR",
"city": "NEW PROVIDENCE",
"state": "NJ",
"postal_code": "079741604",
"telephone_number": "908-464-5270"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LAKE",
"first_name": "KEVIN",
"middle_name": "JOSEPH",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-07-27",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "NJ",
"license": "22DI02044100",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in New Providence, NJ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.