Provider Demographics
NPI:1679674477
Name:GUEVARA, LAURA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:GUEVARA
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 1:519 CHRISTEL DRIVE
Mailing Address - Street 2:
Mailing Address - City:VALDERS
Mailing Address - State:WI
Mailing Address - Zip Code:54245
Mailing Address - Country:US
Mailing Address - Phone:920-775-4531
Mailing Address - Fax:920-775-4180
Practice Address - Street 1:519 CHRISTEL DRIVE
Practice Address - Street 2:
Practice Address - City:VALDERS
Practice Address - State:WI
Practice Address - Zip Code:54245
Practice Address - Country:US
Practice Address - Phone:920-775-4531
Practice Address - Fax:920-775-4180
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48250151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4825015OtherSTATE LICENSE
WI33742000Medicaid