Provider Demographics
NPI:1891870960
Name:LANZER, PAUL C (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:C
Last Name:LANZER
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:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724-0067
Mailing Address - Country:US
Mailing Address - Phone:715-568-1012
Mailing Address - Fax:715-568-1010
Practice Address - Street 1:1604 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724-1647
Practice Address - Country:US
Practice Address - Phone:715-568-1012
Practice Address - Fax:715-568-1010
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI50015231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33656000Medicaid