Provider Demographics
NPI:1114549276
Name:CALLAN, LAURA MICHELLE (DMD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MICHELLE
Last Name:CALLAN
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 1:1244 BROADWAY APT 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5636
Mailing Address - Country:US
Mailing Address - Phone:760-473-9279
Mailing Address - Fax:
Practice Address - Street 1:57 BARRA RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9448
Practice Address - Country:US
Practice Address - Phone:200-282-1305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN48521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice