Provider Demographics
NPI:1093061608
Name:ABBOTT, LAURA EVELYN (DDS)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:EVELYN
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:EVELYN
Other - Last Name:ELLARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6404 POTOMAC HIGHLAND TRAIL
Mailing Address - Street 2:
Mailing Address - City:GREEN BANK
Mailing Address - State:WV
Mailing Address - Zip Code:24944-6404
Mailing Address - Country:US
Mailing Address - Phone:304-456-5433
Mailing Address - Fax:304-456-5439
Practice Address - Street 1:6404 POTOMAC HIGHLAND TRAIL
Practice Address - Street 2:
Practice Address - City:GREEN BANK
Practice Address - State:WV
Practice Address - Zip Code:24944-6404
Practice Address - Country:US
Practice Address - Phone:304-456-5433
Practice Address - Fax:304-456-5439
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4000OtherWV STATE LICENSE