=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154645117
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN ELIZABETH TA D.D.S.,PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2010
-----------------------------------------------------
Last Update Date | 03/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 BROADWAY AVE N SUITE B
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55906-3728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-226-3388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 1ST ST SW
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55905-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-226-3388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D10304
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------