Provider Demographics
NPI:1073671061
Name:MAHAN, LAURA COSTON (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:COSTON
Last Name:MAHAN
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 1:723 COX CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1001
Mailing Address - Country:US
Mailing Address - Phone:256-766-3260
Mailing Address - Fax:256-766-6364
Practice Address - Street 1:723 COX CREEK PKWY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1001
Practice Address - Country:US
Practice Address - Phone:256-766-3260
Practice Address - Fax:256-766-6364
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009985035Medicaid