MEDICARE: DR. JOHN G LAZUR JR. 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	1223G0001X	General Practice Dentistry	DS18163L	PA

General Provider Information

NPI Number	:	1578671079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN G LAZUR JR. DDS

Provider Business Mailing Address
First Line	:	P.O. BOX 280
Second Line	:	2 BALDWIN BLVD
City	:	SHAMOKIN DAM
State	:	PA
Zip	:	17876
Country	:	US
Telephone Number	:	570-743-3300
Fax Number	:	570-743-7555

Provider Business Practice Location Address
First Line	:	2 BALDWIN BLVD.
Second Line	:
City	:	SHAMOKIN DAM
State	:	PA
Zip	:	17876
Country	:	US
Telephone Number	:	570-743-3300
Fax Number	:	570-743-7555

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

Provider Enumeration Date	:	08/26/2006
Last Update Date	:	09/14/2010

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