Provider Demographics
NPI:1740805381
Name:LAZIC, GORAN (RDH)
Entity Type:Individual
Prefix:
First Name:GORAN
Middle Name:
Last Name:LAZIC
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 ANNAPOLIS DR
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-2057
Mailing Address - Country:US
Mailing Address - Phone:773-517-7510
Mailing Address - Fax:
Practice Address - Street 1:109 ANNAPOLIS DR
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-2057
Practice Address - Country:US
Practice Address - Phone:773-517-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020011192124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist