Provider Demographics
NPI:1568631489
Name:JOHN A LAZARUS DDS MS PC
Entity Type:Organization
Organization Name:JOHN A LAZARUS DDS MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAZARUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:248-674-3136
Mailing Address - Street 1:4250 PONTIAC LAKE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1281
Mailing Address - Country:US
Mailing Address - Phone:248-674-3136
Mailing Address - Fax:248-674-3138
Practice Address - Street 1:4250 PONTIAC LAKE RD
Practice Address - Street 2:SUITE A
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-1281
Practice Address - Country:US
Practice Address - Phone:248-674-3136
Practice Address - Fax:248-674-3138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901009548122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty