Healthcare Provider Details

I. General information

NPI: 1841462801
Provider Name (Legal Business Name): GASPER LAZZARA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 SAWGRASS VILLAGE CIR SUITE 3
PONTE VEDRA BEACH FL
32082-5045
US

IV. Provider business mailing address

5000 SAWGRASS VILLAGE CIR SUITE 3
PONTE VEDRA BEACH FL
32082-5045
US

V. Phone/Fax

Practice location:
  • Phone: 904-567-1400
  • Fax: 904-273-6068
Mailing address:
  • Phone: 904-567-1400
  • Fax: 904-273-6068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN4353
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: