Healthcare Provider Details

I. General information

NPI: 1194890418
Provider Name (Legal Business Name): JACK R. LAZER, D.M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MCCORT PLACE
JOHNSTOWN PA
15904
US

IV. Provider business mailing address

105 MCCORT PLACE
JOHNSTOWN PA
15904
US

V. Phone/Fax

Practice location:
  • Phone: 814-269-4404
  • Fax: 814-266-8668
Mailing address:
  • Phone: 814-269-4404
  • Fax: 814-266-8668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS021727L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS021727L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS023637L
License Number StatePA

VIII. Authorized Official

Name: TRACY L. CROYLE
Title or Position: SECRETARY/INS. BILLING
Credential:
Phone: 814-269-4404