Healthcare Provider Details

I. General information

NPI: 1073873162
Provider Name (Legal Business Name): AMANDA BRANNAN LAZO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 RIO EAST CT
CHARLOTTESVILLE VA
22901-8004
US

IV. Provider business mailing address

2536 W SIMMS BLVD
TAMPA FL
33609-5313
US

V. Phone/Fax

Practice location:
  • Phone: 434-817-5437
  • Fax:
Mailing address:
  • Phone: 813-546-9810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401415059
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: