Provider Demographics
NPI:1083620819
Name:PHAN, LAWRENCE L (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:L
Last Name:PHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1330 BEACON ST
Mailing Address - Street 2:SUITE 353
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3282
Mailing Address - Country:US
Mailing Address - Phone:617-734-6300
Mailing Address - Fax:617-734-2732
Practice Address - Street 1:1330 BEACON ST
Practice Address - Street 2:SUITE 353
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3282
Practice Address - Country:US
Practice Address - Phone:617-734-6300
Practice Address - Fax:617-734-2732
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA162541223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics