Basic Information
| Provider Information | |||||||||
| NPI: | 1730610841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAVERDIERE | ||||||||
| FirstName: | JANNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 STEWART ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042403841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073449185 | ||||||||
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| Practice Location | |||||||||
| Address1: | 239 TROJAN RD | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344552480 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2017 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0401416167 | VA | Y | Dental Providers | Dentist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.