Provider Demographics
NPI:1609090968
Name:LAWRENCE R CHURCH DDS INC.
Entity Type:Organization
Organization Name:LAWRENCE R CHURCH DDS INC.
Other - Org Name:INDIO SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-396-5733
Mailing Address - Street 1:46900 MONROE ST STE B201
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-4827
Mailing Address - Country:US
Mailing Address - Phone:760-396-5733
Mailing Address - Fax:760-396-5723
Practice Address - Street 1:46900 MONROE ST
Practice Address - Street 2:SUITE B201
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-4827
Practice Address - Country:US
Practice Address - Phone:760-396-5733
Practice Address - Fax:760-396-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA206151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93862-01OtherDENTICAL PROVIDER NUMBER