Provider Demographics
NPI:1710096078
Name:LAWRENCE, MARK A (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:LAWRENCE
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 1:2570 BROOKSTONE CENTRE PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-4672
Mailing Address - Country:US
Mailing Address - Phone:706-327-6262
Mailing Address - Fax:706-327-1250
Practice Address - Street 1:2570 BROOKSTONE CENTRE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4672
Practice Address - Country:US
Practice Address - Phone:706-327-6262
Practice Address - Fax:706-327-1250
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA0117611223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000831267AMedicaid