Provider Demographics
NPI:1831390376
Name:BACON, LAWRENCE DEAN (DMD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:DEAN
Last Name:BACON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5504 STONEY BROOK RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-7703
Mailing Address - Country:US
Mailing Address - Phone:269-375-1905
Mailing Address - Fax:269-353-8007
Practice Address - Street 1:4426 WEST KL AVE.
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5723
Practice Address - Country:US
Practice Address - Phone:269-353-7700
Practice Address - Fax:269-353-8007
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010120731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice