Provider Demographics
NPI:1851673123
Name:LAWRENCE, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 3RD AVE
Mailing Address - Street 2:APT 4K
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3924
Mailing Address - Country:US
Mailing Address - Phone:570-856-0615
Mailing Address - Fax:570-856-0615
Practice Address - Street 1:1901 UNION BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18109-1676
Practice Address - Country:US
Practice Address - Phone:640-437-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2016-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist