Healthcare Provider Details

I. General information

NPI: 1588634950
Provider Name (Legal Business Name): JOSE F. LAZARO-SAN MIGUEL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8675 MAIDSTONE CT
LARGO FL
33777-1314
US

IV. Provider business mailing address

8675 MAIDSTONE CT
LARGO FL
33777-1314
US

V. Phone/Fax

Practice location:
  • Phone: 727-374-4411
  • Fax:
Mailing address:
  • Phone: 727-374-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number01636
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: