Provider Demographics
NPI:1609247147
Name:DAVIS, LAUREN ASHLEY (DMD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ASHLEY
Other - Last Name:ROYSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3315 S HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7981
Mailing Address - Country:US
Mailing Address - Phone:208-522-4491
Mailing Address - Fax:
Practice Address - Street 1:3315 S HOLMES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7981
Practice Address - Country:US
Practice Address - Phone:208-522-4491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist