Provider Demographics
NPI:1144208133
Name:GRODIN, LAWRENCE B (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:B
Last Name:GRODIN
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 1:1323 ROUTE 9
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-4904
Mailing Address - Country:US
Mailing Address - Phone:845-297-0757
Mailing Address - Fax:
Practice Address - Street 1:1323 ROUTE 9
Practice Address - Street 2:SUITE 209
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-4904
Practice Address - Country:US
Practice Address - Phone:845-297-0757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0375751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY037575OtherNYS LICENSE #