Healthcare Provider Details

I. General information

NPI: 1982270708
Provider Name (Legal Business Name): CRAIG A LAZENBY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 AIRPORT RD
DESTIN FL
32541-2835
US

IV. Provider business mailing address

985 AIRPORT RD
DESTIN FL
32541-2835
US

V. Phone/Fax

Practice location:
  • Phone: 850-988-1777
  • Fax: 850-889-7999
Mailing address:
  • Phone: 850-988-1777
  • Fax: 918-310-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number28135
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: