Healthcare Provider Details

I. General information

NPI: 1417008558
Provider Name (Legal Business Name): JOHN GASPER LAZZARA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 10/01/2012
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 TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4973
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN 18064
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: