=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053705624
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN CARLOS LAZO DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2015
-----------------------------------------------------
Last Update Date | 01/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1611 NW 12TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33136-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-585-5326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18111 NW 82ND CT
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33015-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-527-3716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DN23704
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------