Healthcare Provider Details

I. General information

NPI: 1730322793
Provider Name (Legal Business Name): DR. DENNIS J. LAZZARA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 RANDALL CT
GENEVA IL
60134-3911
US

IV. Provider business mailing address

1129 RANDALL CT
GENEVA IL
60134-3911
US

V. Phone/Fax

Practice location:
  • Phone: 630-232-2277
  • Fax: 630-232-0354
Mailing address:
  • Phone: 630-232-2277
  • Fax: 630-232-0354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021.000906
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: