Healthcare Provider Details

I. General information

NPI: 1164611083
Provider Name (Legal Business Name): LAURA E GREEN GENTILE AUD, CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA E GREEN GENTILE AUD, CCC-A

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 BEACHVIEW ST SUITE 240
DALLAS TX
75218-3700
US

IV. Provider business mailing address

1130 BEACHVIEW ST SUITE 240
DALLAS TX
75218-3700
US

V. Phone/Fax

Practice location:
  • Phone: 214-324-0418
  • Fax: 214-324-0693
Mailing address:
  • Phone: 214-324-0418
  • Fax: 214-324-0693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number50934
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: