Provider Demographics
NPI:1033234554
Name:SPROUSE, LAWRENCE HENRY JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:HENRY
Last Name:SPROUSE
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2452 BLACK ROCK TPKE STE 12
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-2407
Mailing Address - Country:US
Mailing Address - Phone:203-374-3886
Mailing Address - Fax:
Practice Address - Street 1:2452 BLACK ROCK TPKE
Practice Address - Street 2:SUITE 12
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-2407
Practice Address - Country:US
Practice Address - Phone:203-374-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT40351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice