Provider Demographics
NPI:1902954282
Name:PRESCOTT, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:PRESCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 HIDDEN ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-7459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:340 MAGNOLIA CIR
Practice Address - Street 2:
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403-5604
Practice Address - Country:US
Practice Address - Phone:850-283-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH19316124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist