Provider Demographics
NPI:1083053060
Name:VACCARIELLO, LAURA HANSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:HANSON
Last Name:VACCARIELLO
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 1:482 MERCANTILE PL
Mailing Address - Street 2:STE 104
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-2102
Mailing Address - Country:US
Mailing Address - Phone:803-548-4255
Mailing Address - Fax:803-409-0333
Practice Address - Street 1:482 MERCANTILE PL
Practice Address - Street 2:STE 104
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-2102
Practice Address - Country:US
Practice Address - Phone:803-548-4255
Practice Address - Fax:803-409-0333
Is Sole Proprietor?:No
Enumeration Date:2013-06-23
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87061223X0400X
MADL11860204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery