Healthcare Provider Details

I. General information

NPI: 1568685147
Provider Name (Legal Business Name): RALPH LAZARO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 WALKER RD SUITE 6
GREAT FALLS VA
22066-2833
US

IV. Provider business mailing address

737 WALKER RD SUITE 6
GREAT FALLS VA
22066-2833
US

V. Phone/Fax

Practice location:
  • Phone: 703-759-3011
  • Fax: 703-759-6030
Mailing address:
  • Phone: 703-759-3011
  • Fax: 703-759-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401004449
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: