MEDICARE: DR. ERIC SCOTT LAWRENCE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	30-01-7373	OH

General Provider Information

NPI Number	:	1124140025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC SCOTT LAWRENCE DDS

Provider Business Mailing Address
First Line	:	1413 GOLDEN GATE BLVD STE 120
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-3420
Country	:	US
Telephone Number	:	440-449-1550
Fax Number	:	440-449-8995

Provider Business Practice Location Address
First Line	:	1413 GOLDEN GATE BLVD STE 120
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-3420
Country	:	US
Telephone Number	:	440-449-1550
Fax Number	:	440-449-8995

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	03/28/2009

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