Provider Demographics
NPI:1225235203
Name:LAUDENBACH, JOEL MARTIN (DMD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:MARTIN
Last Name:LAUDENBACH
Suffix:
Gender:M
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 ABBEY PL
Practice Address - Street 2:STE 220
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3835
Practice Address - Country:US
Practice Address - Phone:704-512-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01971223D0001X, 1223G0001X, 125Q00000X, 122300000X
CA46091122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice
No125Q00000XDental ProvidersOral Medicinist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA087977OtherMEDICARE OPT-OUT
NC1225235203Medicaid