=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366576704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAVONNE MARIE SAWYER DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 04/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3602 6TH AVE STE 104
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-777-4461
-----------------------------------------------------
Fax | 253-752-0220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 828 S FAIRMONT AVE
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-333-8484
-----------------------------------------------------
Fax | 209-333-1428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 32587
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8096
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DE00008096
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------