Provider Demographics
NPI:1619180148
Name:FOGLE, LAURA L (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:L
Last Name:FOGLE
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933THREE MILE RD., NW STE 102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8216
Mailing Address - Country:US
Mailing Address - Phone:616-784-5993
Mailing Address - Fax:616-784-5995
Practice Address - Street 1:933THREE MILE RD., NW STE 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8216
Practice Address - Country:US
Practice Address - Phone:616-784-5993
Practice Address - Fax:616-784-5995
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010166821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics