Provider Demographics
NPI:1194890418
Name:JACK R. LAZER, D.M.D., P.C.
Entity type:Organization
Organization Name:JACK R. LAZER, D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/INS. BILLING
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CROYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-269-4404
Mailing Address - Street 1:105 MCCORT PLACE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904
Mailing Address - Country:US
Mailing Address - Phone:814-269-4404
Mailing Address - Fax:814-266-8668
Practice Address - Street 1:105 MCCORT PLACE
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904
Practice Address - Country:US
Practice Address - Phone:814-269-4404
Practice Address - Fax:814-266-8668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021727L122300000X, 1223G0001X
PADS023637L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty