Provider Demographics
NPI:1508188244
Name:LAFAZANOS DENTAL PC
Entity Type:Organization
Organization Name:LAFAZANOS DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SPIROS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAFAZANOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-455-5490
Mailing Address - Street 1:820 E TERRA COTTA AVE
Mailing Address - Street 2:SUITE 218/220
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3649
Mailing Address - Country:US
Mailing Address - Phone:815-455-5490
Mailing Address - Fax:815-455-5498
Practice Address - Street 1:820 E TERRA COTTA AVE
Practice Address - Street 2:SUITE 218/220
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3649
Practice Address - Country:US
Practice Address - Phone:815-455-5490
Practice Address - Fax:815-455-5498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190233071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty