Provider Demographics
NPI:1821180068
Name:BLACKSTONE, LAWRENCE ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:ALAN
Last Name:BLACKSTONE
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 1:855 E PALATINE RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-5500
Mailing Address - Country:US
Mailing Address - Phone:847-359-0200
Mailing Address - Fax:847-359-7483
Practice Address - Street 1:855 E PALATINE RD
Practice Address - Street 2:SUITE 180
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-5500
Practice Address - Country:US
Practice Address - Phone:847-359-0200
Practice Address - Fax:847-359-7483
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A12282122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist