Healthcare Provider Details

I. General information

NPI: 1821095308
Provider Name (Legal Business Name): LAQUIA VINSON D.D.S, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR SUITE 4205
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

705 RILEY HOSPITAL DR SUITE 4205
INDIANAPOLIS IN
46202-5109
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-9604
  • Fax: 317-948-0760
Mailing address:
  • Phone: 317-944-9604
  • Fax: 317-948-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12010589A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: