Provider Demographics
NPI:1437366457
Name:LACKMAN, JAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:LACKMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MONUMENT RD
Mailing Address - Street 2:SUITE #4
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1726
Mailing Address - Country:US
Mailing Address - Phone:610-667-7405
Mailing Address - Fax:610-667-7409
Practice Address - Street 1:200 MONUMENT ROAD
Practice Address - Street 2:SUITE #4
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1726
Practice Address - Country:US
Practice Address - Phone:610-667-7405
Practice Address - Fax:610-667-7409
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017812L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist