1790931293 NPI number — DR. LAURA ANN GUTTORMSEN D.D.S.

Table of content: DR. LAURA ANN GUTTORMSEN D.D.S. (NPI 1790931293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790931293 NPI number — DR. LAURA ANN GUTTORMSEN D.D.S.

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROTHMAN
Provider Other First Name:
LAURA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790931293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3415 30TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53144-1622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-654-0267
Provider Business Mailing Address Fax Number:
262-654-6939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3415 30TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53144-1622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-654-0267
Provider Business Practice Location Address Fax Number:
262-654-6939
Provider Enumeration Date:
08/15/2008

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:  6307-15 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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