Healthcare Provider Details

I. General information

NPI: 1851572911
Provider Name (Legal Business Name): MARC EVAN LAZARE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E 61ST ST SUITE 14A
NEW YORK NY
10065-8183
US

IV. Provider business mailing address

115 E 61ST ST SUITE 14A
NEW YORK NY
10065-8183
US

V. Phone/Fax

Practice location:
  • Phone: 212-861-2599
  • Fax: 212-861-2540
Mailing address:
  • Phone: 212-861-2599
  • Fax: 212-861-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046840
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: