Provider Demographics
NPI:1154194041
Name:LAWRENCE, MADLYN
Entity type:Individual
Prefix:
First Name:MADLYN
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4756
Mailing Address - Country:US
Mailing Address - Phone:217-828-2687
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-389-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist