Provider Demographics
NPI:1598179483
Name:RAZDOLSKY, LANIEL
Entity Type:Individual
Prefix:
First Name:LANIEL
Middle Name:
Last Name:RAZDOLSKY
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 1:133 E LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1326
Mailing Address - Country:US
Mailing Address - Phone:847-234-6440
Mailing Address - Fax:
Practice Address - Street 1:133 E LAUREL AVE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1326
Practice Address - Country:US
Practice Address - Phone:847-234-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029812122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist