Provider Demographics
NPI:1497792071
Name:LAVINE, WILLIAM SIDNEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:SIDNEY
Last Name:LAVINE
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 1:928 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2227
Mailing Address - Country:US
Mailing Address - Phone:860-233-6266
Mailing Address - Fax:860-233-6267
Practice Address - Street 1:928 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2227
Practice Address - Country:US
Practice Address - Phone:860-233-6266
Practice Address - Fax:860-233-6267
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT46681223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4668OtherSTATE DENTAL LICENSE #