Healthcare Provider Details

I. General information

NPI: 1053523548
Provider Name (Legal Business Name): LAURA L. FOGLE, D.D.S., M.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 THREE MILE RD., NW
GRAND RAPIDS MI
49544-8216
US

IV. Provider business mailing address

890 THREE MILE RD., NW
GRAND RAPIDS MI
49544-8216
US

V. Phone/Fax

Practice location:
  • Phone: 616-784-5993
  • Fax: 616-784-5995
Mailing address:
  • Phone: 616-784-5993
  • Fax: 616-784-5995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901016682
License Number StateMI

VIII. Authorized Official

Name: DR. LAURA L. FOGLE
Title or Position: OWNER
Credential: D.D.S, M.S.
Phone: 616-784-5993