Provider Demographics
NPI:1043641772
Name:JERROLD, LAURANCE (DDS)
Entity type:Individual
Prefix:
First Name:LAURANCE
Middle Name:
Last Name:JERROLD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 ASPEN DRIVE EAST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797
Mailing Address - Country:US
Mailing Address - Phone:904-710-5125
Mailing Address - Fax:
Practice Address - Street 1:96 ASPEN DRIVE EAST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797
Practice Address - Country:US
Practice Address - Phone:904-710-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0320811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics