MEDICARE: LAWANA FUQUAY

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	042702	NY

General Provider Information

NPI Number	:	1659461747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWANA FUQUAY

Provider Business Mailing Address
First Line	:	415 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-3111
Country	:	US
Telephone Number	:	719-546-3333
Fax Number	:

Provider Business Practice Location Address
First Line	:	728 RIDGE RD E
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14621-1719
Country	:	US
Telephone Number	:	585-663-1624
Fax Number	:

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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Directions to “ LAWANA FUQUAY ” Practice Location

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