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General NPI Number Information
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NPI Number | 1851673123
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Entity Type | Individual
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Provider Name | JACK LAWRENCE
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Gender | Male
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Dates
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Enumeration Date | 09/13/2011
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Last Update Date | 06/04/2016
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Provider Practice Location Address
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Address Line | 1901 UNION BLVD
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City | ALLENTOWN
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State | PA
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Zip | 18109-1676
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Country | US
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Telephone | 640-437-5353
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Fax |
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Provider Business Mailing Address
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Address Line | 135 3RD AVE APT 4K
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City | MINEOLA
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State | NY
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Zip | 11501-3924
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Country | US
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Telephone | 570-856-0615
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Fax | 570-856-0615
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 057478
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License Number State | NY
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