Provider Demographics
NPI:1427676006
Name:EASOW, LARA JOSEPH (DMD)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:JOSEPH
Last Name:EASOW
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6281 JACKSTAFF DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1171
Mailing Address - Country:US
Mailing Address - Phone:832-269-8222
Mailing Address - Fax:
Practice Address - Street 1:12770 MERIT DR STE 850
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-1438
Practice Address - Country:US
Practice Address - Phone:832-269-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX362961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice