Healthcare Provider Details

I. General information

NPI: 1235248170
Provider Name (Legal Business Name): ROBERT M LAZERSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 ROSWELL RD SUITE 110
MARIETTA GA
30062-4996
US

IV. Provider business mailing address

3020 ROSWELL RD SUITE 110
MARIETTA GA
30062-4996
US

V. Phone/Fax

Practice location:
  • Phone: 770-565-8730
  • Fax: 770-509-2323
Mailing address:
  • Phone: 770-565-8730
  • Fax: 770-509-2323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number008132
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: