Provider Demographics
NPI:1043661028
Name:LAZIN, JAMIE (DMD, MS, MSD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:
Last Name:LAZIN
Suffix:
Gender:M
Credentials:DMD, MS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E 58TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2519
Mailing Address - Country:US
Mailing Address - Phone:404-931-1576
Mailing Address - Fax:
Practice Address - Street 1:11 E 58TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2519
Practice Address - Country:US
Practice Address - Phone:404-931-1576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012549A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1201549AOtherDENTAL LICENSE