Healthcare Provider Details

I. General information

NPI: 1457542417
Provider Name (Legal Business Name): JEREMY LASSETTER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PALISADES DR SUITE 210
ALBANY NY
12205-6433
US

IV. Provider business mailing address

5 PALISADES DR SUITE 210
ALBANY NY
12205-6433
US

V. Phone/Fax

Practice location:
  • Phone: 518-348-0634
  • Fax: 518-426-3221
Mailing address:
  • Phone: 518-348-0634
  • Fax: 518-426-3221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8682
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number055974
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: