Provider Demographics
NPI:1437222684
Name:BRACKEN, LAURA ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANN
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 3RD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-6816
Mailing Address - Country:US
Mailing Address - Phone:812-373-9912
Mailing Address - Fax:812-373-9920
Practice Address - Street 1:901 3RD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6816
Practice Address - Country:US
Practice Address - Phone:812-373-9912
Practice Address - Fax:812-373-9920
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010438A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200387920AMedicaid