Provider Demographics
NPI:1376678698
Name:LAWRENCE, J RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:J RICHARD
Middle Name:
Last Name:LAWRENCE
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 1:232 BELLE MEAD RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733
Mailing Address - Country:US
Mailing Address - Phone:631-689-2650
Mailing Address - Fax:631-689-2651
Practice Address - Street 1:232 BELLE MEAD RD
Practice Address - Street 2:SUITE 7
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733
Practice Address - Country:US
Practice Address - Phone:631-689-2650
Practice Address - Fax:631-689-2651
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01200146Medicaid