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General NPI Number Information
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NPI Number | 1619180148
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Entity Type | Individual
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Provider Name | LAURA L. FOGLE D.D.S., M.S.
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Gender | Female
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 03/29/2012
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Provider Practice Location Address
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Address Line | 933THREE MILE RD., NW STE 102
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City | GRAND RAPIDS
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State | MI
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Zip | 49544-8216
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Country | US
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Telephone | 616-784-5993
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Fax | 616-784-5995
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Provider Business Mailing Address
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Address Line | 933THREE MILE RD., NW STE 102
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City | GRAND RAPIDS
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State | MI
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Zip | 49544-8216
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Country | US
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Telephone | 616-784-5993
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Fax | 616-784-5995
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 2901016682
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License Number State | MI
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