Provider Demographics
NPI:1679449474
Name:LAWRENCE, TIAWANA
Entity type:Individual
Prefix:MS
First Name:TIAWANA
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13106 CYGNUS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-4270
Mailing Address - Country:US
Mailing Address - Phone:252-883-1238
Mailing Address - Fax:
Practice Address - Street 1:13106 CYGNUS
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-4270
Practice Address - Country:US
Practice Address - Phone:252-883-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-17
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207QA0505X122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty