Provider Demographics
NPI:1598898744
Name:MCCAULEY, LAURIE K (DMD PHD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:K
Last Name:MCCAULEY
Suffix:
Gender:F
Credentials:DMD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1078
Mailing Address - Country:US
Mailing Address - Phone:734-764-1562
Mailing Address - Fax:734-763-3389
Practice Address - Street 1:1011 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1078
Practice Address - Country:US
Practice Address - Phone:734-764-1562
Practice Address - Fax:734-763-3389
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016012122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI195816298OtherBCBS OF MI MED SURGICAL
MID160120OtherBCBS OF MI DENTAL
MI195816298OtherBCBS OF MI MED SURGICAL
MI0N65440012Medicare PIN