Provider Demographics
NPI:1609455278
Name:GLYNN, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:GLYNN
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 1:7 SLEEPY HOLW
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-1627
Mailing Address - Country:US
Mailing Address - Phone:508-404-7869
Mailing Address - Fax:
Practice Address - Street 1:1209 SOMERSET AVE
Practice Address - Street 2:
Practice Address - City:DIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02715-1264
Practice Address - Country:US
Practice Address - Phone:508-692-8289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859336122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program