Provider Demographics
NPI:1255976312
Name:ETHAN E. LAWLER, D.D.S., S.C.
Entity type:Organization
Organization Name:ETHAN E. LAWLER, D.D.S., S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUEANE
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:NOVACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-374-2856
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:LAKE NEBAGAMON
Mailing Address - State:WI
Mailing Address - Zip Code:54849-0520
Mailing Address - Country:US
Mailing Address - Phone:715-374-2856
Mailing Address - Fax:715-374-2299
Practice Address - Street 1:6881 SOUTH LAKE AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE NEBAGAMON
Practice Address - State:WI
Practice Address - Zip Code:54849-9264
Practice Address - Country:US
Practice Address - Phone:715-374-2856
Practice Address - Fax:715-374-2299
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ETHAN E. LAWLER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-13
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty