Provider Demographics
NPI:1245429604
Name:JOHN LAZZARA, DDS, PA
Entity Type:Organization
Organization Name:JOHN LAZZARA, DDS, PA
Other - Org Name:LAZZARA ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZZARA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-806-2238
Mailing Address - Street 1:4184 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5833
Mailing Address - Country:US
Mailing Address - Phone:904-270-8750
Mailing Address - Fax:904-270-8755
Practice Address - Street 1:4184 3RD ST S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-5833
Practice Address - Country:US
Practice Address - Phone:904-270-8750
Practice Address - Fax:904-270-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 180641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty