=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538848528
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN E GORNALL RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2023
-----------------------------------------------------
Last Update Date | 07/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4912 W ST JOE HWY
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48917-4090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 177-193-8075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 566 RILEY ST
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48910-3247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-969-0363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 2902020252
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------