Provider Demographics
NPI:1649609587
Name:MINTZER, LAWRENCE
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:MINTZER
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 1:23100 CHERRY HILL ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1493
Mailing Address - Country:US
Mailing Address - Phone:313-274-5060
Mailing Address - Fax:
Practice Address - Street 1:23100 CHERRY HILL ST
Practice Address - Street 2:SUITE 2
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1493
Practice Address - Country:US
Practice Address - Phone:313-274-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010768122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist