MEDICARE: DR. JOHN GASPER LAZZARA D.D.S.

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	4973	LA
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN 18064	FL

General Provider Information

NPI Number	:	1417008558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN GASPER LAZZARA D.D.S.

Provider Business Mailing Address
First Line	:	4184 3RD ST S
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-5833
Country	:	US
Telephone Number	:	904-270-8750
Fax Number	:	904-270-8755

Provider Business Practice Location Address
First Line	:	4184 3RD ST S
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-5833
Country	:	US
Telephone Number	:	904-270-8750
Fax Number	:	904-270-8755

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	10/01/2012

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