Provider Demographics
NPI:1609303866
Name:NEITZKE, LAUREN OLIVIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:OLIVIA
Last Name:NEITZKE
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 1:6437 BROOKLYN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2141
Mailing Address - Country:US
Mailing Address - Phone:763-531-7177
Mailing Address - Fax:
Practice Address - Street 1:6437 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429
Practice Address - Country:US
Practice Address - Phone:763-531-7177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13825122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist