Provider Demographics
NPI:1417008558
Name:LAZZARA, JOHN GASPER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GASPER
Last Name:LAZZARA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA49731223X0400X
FLDN 180641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics