Healthcare Provider Details

I. General information

NPI: 1245429604
Provider Name (Legal Business Name): JOHN LAZZARA, DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4184 3RD ST S
JACKSONVILLE BEACH FL
32250-5833
US

IV. Provider business mailing address

4184 3RD ST S
JACKSONVILLE BEACH FL
32250-5833
US

V. Phone/Fax

Practice location:
  • Phone: 904-270-8750
  • Fax: 904-270-8755
Mailing address:
  • Phone: 904-270-8750
  • Fax: 904-270-8755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN 18064
License Number StateFL

VIII. Authorized Official

Name: DR. JOHN LAZZARA
Title or Position: PRESIDENT
Credential: DDS
Phone: 904-806-2238