Provider Demographics
NPI:1447363221
Name:LAZOPOULOS, GEORGE (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:LAZOPOULOS
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 1:111 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-1001
Mailing Address - Country:US
Mailing Address - Phone:815-962-0394
Mailing Address - Fax:815-962-5163
Practice Address - Street 1:111 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-1001
Practice Address - Country:US
Practice Address - Phone:815-962-0394
Practice Address - Fax:815-962-5163
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002671Medicaid