Provider Demographics
NPI:1255308011
Name:GOLDBLATT, LAWRENCE I (DDS MSD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:I
Last Name:GOLDBLATT
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 W MICHIGAN ST
Mailing Address - Street 2:ROOM 285
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5211
Mailing Address - Country:US
Mailing Address - Phone:317-274-7668
Mailing Address - Fax:317-274-3346
Practice Address - Street 1:1121 W MICHIGAN ST
Practice Address - Street 2:ROOM 285
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5211
Practice Address - Country:US
Practice Address - Phone:317-274-7668
Practice Address - Fax:317-274-3346
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120072071223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000211690OtherANTHEM
IN899580Medicare ID - Type Unspecified
000000211690OtherANTHEM