Healthcare Provider Details

I. General information

NPI: 1942770334
Provider Name (Legal Business Name): LAURA OPIE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 PRAIRIE ST
PRAIRIE DU SAC WI
53578-2041
US

IV. Provider business mailing address

1250 PRAIRIE ST
PRAIRIE DU SAC WI
53578-2041
US

V. Phone/Fax

Practice location:
  • Phone: 608-643-8505
  • Fax:
Mailing address:
  • Phone: 608-643-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10757
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: