Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 12006116A | IN |
NPI | 1104909993 |
---|---|
Provider Name | Ross L Lawrence |
First Address | La Porte, IN 46350-3201 |
Second Address | La Porte, IN 46350-3175 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2006 |
Last Update Date | 08/07/2007 |