Provider Demographics
NPI:1073527263
Name:LAVRISA, STEPHEN JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOHN
Last Name:LAVRISA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 WILLIAMSBURG AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-1108
Mailing Address - Country:US
Mailing Address - Phone:630-262-9696
Mailing Address - Fax:630-262-9685
Practice Address - Street 1:2631 WILLIAMSBURG AVE STE 103
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-262-9696
Practice Address - Fax:630-262-9685
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190219791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice