Provider Demographics
NPI:1003937301
Name:LAFAYETTE, JEAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:M
Last Name:LAFAYETTE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 WATERVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001
Mailing Address - Country:US
Mailing Address - Phone:860-983-6725
Mailing Address - Fax:860-243-5681
Practice Address - Street 1:ONE NORTHWESTERN DRIVE
Practice Address - Street 2:SUITE #201
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002
Practice Address - Country:US
Practice Address - Phone:860-242-0700
Practice Address - Fax:860-243-5681
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT020007394CT04OtherBCBS