Provider Demographics
NPI:1174577811
Name:LANSFORD, JEREMY SHANE (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:SHANE
Last Name:LANSFORD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 MARBERN DR
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-1535
Mailing Address - Country:US
Mailing Address - Phone:210-455-5571
Mailing Address - Fax:
Practice Address - Street 1:180 MARBERN DR
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-1535
Practice Address - Country:US
Practice Address - Phone:210-455-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009319122300000X
TN8803122300000X
VA0401412410122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist