Provider Demographics
NPI:1417504192
Name:SCULLY, LAURA M
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:SCULLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7013 W FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-1923
Mailing Address - Country:US
Mailing Address - Phone:773-517-8384
Mailing Address - Fax:
Practice Address - Street 1:7013 W FARRAGUT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-1923
Practice Address - Country:US
Practice Address - Phone:773-517-8384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020007556124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist