Provider Demographics
NPI:1073873162
Name:LAZO, AMANDA BRANNAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:BRANNAN
Last Name:LAZO
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 1:2536 W SIMMS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-5313
Mailing Address - Country:US
Mailing Address - Phone:813-546-9810
Mailing Address - Fax:
Practice Address - Street 1:895 RIO EAST CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-8004
Practice Address - Country:US
Practice Address - Phone:434-817-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE390200000X
VA04014150591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program