Provider Demographics
NPI:1558402644
Name:BLANK, LAWRENCE W (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:W
Last Name:BLANK
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 1:15020 SHADY GROVE ROAD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850
Mailing Address - Country:US
Mailing Address - Phone:301-738-2111
Mailing Address - Fax:301-738-6438
Practice Address - Street 1:15020 SHADY GROVE RD
Practice Address - Street 2:SUITE 325
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3364
Practice Address - Country:US
Practice Address - Phone:301-738-2111
Practice Address - Fax:301-738-6438
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD105991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice