Provider Demographics
NPI:1477057131
Name:ARISTIZABAL, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ARISTIZABAL
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 1:13153 OLD HICKORY BLVD APT 918
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4988
Mailing Address - Country:US
Mailing Address - Phone:205-482-7857
Mailing Address - Fax:
Practice Address - Street 1:2340 LEBANON PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37214
Practice Address - Country:US
Practice Address - Phone:615-830-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TNDS00000107871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDS0000010787Medicaid