Provider Demographics
NPI:1003225236
Name:LAFFERTY, DAN JR (DMD)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:LAFFERTY
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 KEILY STREET
Mailing Address - Street 2:BUREAU OF MEDICINE & SURGERY - CENTRALIZED CREDENTIALI
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212
Mailing Address - Country:US
Mailing Address - Phone:757-953-7011
Mailing Address - Fax:
Practice Address - Street 1:4550 EUBANK BLVD NE STE 101
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2565
Practice Address - Country:US
Practice Address - Phone:505-292-8588
Practice Address - Fax:505-292-3100
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10121122300000X
NMDD4838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist