Provider Demographics
NPI:1558989889
Name:LAWRENCE, JASON ANDREW
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ANDREW
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 ROWLOCK RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3317
Mailing Address - Country:US
Mailing Address - Phone:757-488-3987
Mailing Address - Fax:
Practice Address - Street 1:3410 COUNTY ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3205
Practice Address - Country:US
Practice Address - Phone:757-393-2968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014170211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty