Provider Demographics
NPI:1639292469
Name:LAWSON, THEODORE JAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:JAN
Last Name:LAWSON
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 1:2012 LAKE AIR DR
Mailing Address - Street 2:ST A
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-7901
Mailing Address - Country:US
Mailing Address - Phone:254-751-7100
Mailing Address - Fax:254-751-7144
Practice Address - Street 1:2012 LAKE AIR DR
Practice Address - Street 2:ST A
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-7901
Practice Address - Country:US
Practice Address - Phone:254-751-7100
Practice Address - Fax:254-751-7144
Is Sole Proprietor?:No
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX191991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice