Provider Demographics
NPI:1811099765
Name:CHILD, LAWRENCE JOHN (DDS, PC)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:JOHN
Last Name:CHILD
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 5TH AVE W
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1202
Mailing Address - Country:US
Mailing Address - Phone:208-934-4610
Mailing Address - Fax:208-934-0901
Practice Address - Street 1:126 5TH AVE W
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1202
Practice Address - Country:US
Practice Address - Phone:208-934-4610
Practice Address - Fax:208-934-0901
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD14731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice