Provider Demographics
NPI:1104855634
Name:LEVIN, LAWRENCE M (DMD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:M
Last Name:LEVIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:5 WHITE BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-3580
Mailing Address - Fax:215-662-7445
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:5 WHITE BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3580
Practice Address - Fax:215-662-7445
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421768204E00000X
PADS025560L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012815230001Medicaid
U32156Medicare UPIN
PA0012815230001Medicaid