Provider Demographics
NPI:1821203993
Name:LAWRENCE, JEANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 AMERICAN WAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3938
Mailing Address - Country:US
Mailing Address - Phone:847-680-1111
Mailing Address - Fax:
Practice Address - Street 1:1216 AMERICAN WAY
Practice Address - Street 2:SUITE 104
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3938
Practice Address - Country:US
Practice Address - Phone:847-680-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL691450Medicare PIN
IL691450Medicare UPIN