MEDICARE: JENNIFER LAQUAY

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	261QD0000X	Dental Clinic/Center	8320	NC

General Provider Information

NPI Number	:	1265606958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JENNIFER LAQUAY

Provider Business Mailing Address
First Line	:	4742 LONG BEACH RD SE
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-8721
Country	:	US
Telephone Number	:	910-457-7167
Fax Number	:	910-457-9650

Provider Business Practice Location Address
First Line	:	4742 LONG BEACH RD SE
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-8721
Country	:	US
Telephone Number	:	910-457-7167
Fax Number	:	910-457-9650

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. JENNIFER LAQUAY
Credential	:	DMD
Telephone Number	:	910-457-7167

Provider Enumeration Date	:	04/15/2008
Last Update Date	:	04/15/2008

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Directions to “JENNIFER LAQUAY ” Practice Location

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