Healthcare Provider Details

I. General information

NPI: 1578728457
Provider Name (Legal Business Name): LAUREN PECTYO NAMSUPAK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3412 UNIVERSITY AVE
MORGANTOWN WV
26505-7220
US

IV. Provider business mailing address

3412 UNIVERSITY AVE
MORGANTOWN WV
26505-7220
US

V. Phone/Fax

Practice location:
  • Phone: 304-381-3331
  • Fax:
Mailing address:
  • Phone: 304-381-3331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS038864
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3832
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3832
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: