Provider Demographics
NPI:1154778298
Name:LAWSON, MALLORIE NICOLE (DDS)
Entity type:Individual
Prefix:DR
First Name:MALLORIE
Middle Name:NICOLE
Last Name:LAWSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MALLORIE
Other - Middle Name:NICOLE
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3711 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1904
Mailing Address - Country:US
Mailing Address - Phone:317-941-7300
Mailing Address - Fax:
Practice Address - Street 1:3711 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1904
Practice Address - Country:US
Practice Address - Phone:317-941-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012482A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice