Provider Demographics
NPI:1629038328
Name:GOTTESMAN, LAWRENCE (DDS)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:GOTTESMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:LAWRENCE
Other - Middle Name:
Other - Last Name:GOTTESMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:66 LINCOLN CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5777
Mailing Address - Country:US
Mailing Address - Phone:516-678-4004
Mailing Address - Fax:516-678-4564
Practice Address - Street 1:66 LINCOLN COURT
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570
Practice Address - Country:US
Practice Address - Phone:516-678-4004
Practice Address - Fax:516-678-4564
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0332161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02721855Medicaid