Provider Demographics
NPI:1083457220
Name:LAZO, ANDY (DMD)
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:LAZO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:LAZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:430 S LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2228
Practice Address - Country:US
Practice Address - Phone:770-252-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0352121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice