The holder whose full name is LAKE, GLEN IVAN,come from NEW HAVEN IN,hold the CSR-Dentist license(NO.12003919B) which status is Expired.
| Name | LAKE, GLEN IVAN |
|---|---|
| License Number | 12003919B |
| License Type | CSR-Dentist |
| License Status | Expired |
| City | NEW HAVEN |
| State | IN |