Provider Demographics
NPI:1245913037
Name:LAWRENCE, JIMMIE LORETTA (RDH)
Entity type:Individual
Prefix:
First Name:JIMMIE
Middle Name:LORETTA
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4800
Mailing Address - Country:US
Mailing Address - Phone:210-652-5515
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W
Practice Address - Street 2:
Practice Address - City:RANDOLPH AFB
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-748-0314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13340124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist