MEDICARE: MRS. LAURA E GREEN GENTILE AUD, CCC-A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	50934	TX

General Provider Information

NPI Number	:	1164611083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA E GREEN GENTILE AUD, CCC-A

Provider Business Mailing Address
First Line	:	1130 BEACHVIEW ST
Second Line	:	SUITE 240
City	:	DALLAS
State	:	TX
Zip	:	75218-3700
Country	:	US
Telephone Number	:	214-324-0418
Fax Number	:	214-324-0693

Provider Business Practice Location Address
First Line	:	1130 BEACHVIEW ST
Second Line	:	SUITE 240
City	:	DALLAS
State	:	TX
Zip	:	75218-3700
Country	:	US
Telephone Number	:	214-324-0418
Fax Number	:	214-324-0693

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	03/06/2023

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