Healthcare Provider Details

I. General information

NPI: 1144361296
Provider Name (Legal Business Name): LAURIN G RACKHAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1834 S STATE ST
OREM UT
84097-8109
US

IV. Provider business mailing address

1834 S STATE ST
OREM UT
84097-8109
US

V. Phone/Fax

Practice location:
  • Phone: 801-224-0222
  • Fax: 801-226-7560
Mailing address:
  • Phone: 801-224-0222
  • Fax: 801-226-7560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number145560-9921
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: