Provider Demographics
NPI:1265511091
Name:LATTANZI, DAVID A (DDS)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:LATTANZI
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 1:700 WEST PIKE STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301
Mailing Address - Country:US
Mailing Address - Phone:304-622-4828
Mailing Address - Fax:304-624-0977
Practice Address - Street 1:700 WEST PIKE STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-622-4828
Practice Address - Fax:304-624-0977
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0138397000Medicaid
T32444Medicare UPIN
LA0608181Medicare ID - Type Unspecified