Provider Demographics
NPI:1003027160
Name:ADDVENSKY, LAURIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:
Last Name:ADDVENSKY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 W RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3142
Mailing Address - Country:US
Mailing Address - Phone:201-652-0060
Mailing Address - Fax:201-652-7687
Practice Address - Street 1:79 W RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3142
Practice Address - Country:US
Practice Address - Phone:201-652-0060
Practice Address - Fax:201-652-7687
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDIO17413122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist