Provider Demographics
NPI:1043350424
Name:LEVENS, LAWRENCE JAY (DDS, MS, PC)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:JAY
Last Name:LEVENS
Suffix:
Gender:M
Credentials:DDS, MS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 N BALLAS RD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2321
Mailing Address - Country:US
Mailing Address - Phone:314-872-3218
Mailing Address - Fax:314-872-3219
Practice Address - Street 1:2821 N BALLAS RD
Practice Address - Street 2:SUITE 155
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2321
Practice Address - Country:US
Practice Address - Phone:314-872-3218
Practice Address - Fax:314-872-3219
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0145621223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO014562OtherSTATE LICENSE NUMBER
MO1366646622OtherNPI TYPE 2