1750355343 NPI number — DR. LAURA M GUSHUE D.M.D.

Table of content: DR. LAURA M GUSHUE D.M.D. (NPI 1750355343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750355343 NPI number — DR. LAURA M GUSHUE D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSHUE
Provider First Name:
LAURA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750355343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6928 RYAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDINA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44256-8878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-725-7488
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 LIVINGSTON AVE
Provider Second Line Business Practice Location Address:
LORAIN COUNTY HEALTH AND DENTISTRY
Provider Business Practice Location Address City Name:
LORAIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-233-0100
Provider Business Practice Location Address Fax Number:
440-242-2400
Provider Enumeration Date:
02/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  19711 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3579 . This is a "DORAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 341957404065 . This is a "CARESOURE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0952689 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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