Provider Demographics
NPI:1477646628
Name:LAURA, JOAN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:C
Last Name:LAURA
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 1:2326 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2839
Mailing Address - Country:US
Mailing Address - Phone:315-438-3333
Mailing Address - Fax:315-437-7276
Practice Address - Street 1:2326 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-2839
Practice Address - Country:US
Practice Address - Phone:315-438-3333
Practice Address - Fax:315-437-7276
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0422831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2GHMedicaid