Healthcare Provider Details

I. General information

NPI: 1619180148
Provider Name (Legal Business Name): LAURA L. FOGLE D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933THREE MILE RD., NW STE 102
GRAND RAPIDS MI
49544-8216
US

IV. Provider business mailing address

933THREE MILE RD., NW STE 102
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:
Title or Position:
Credential:
Phone: