Provider Demographics
NPI:1689119190
Name:LAURICH DENTISTRY FARMINGTON
Entity Type:Organization
Organization Name:LAURICH DENTISTRY FARMINGTON
Other - Org Name:LAURICH DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LAURICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-553-0110
Mailing Address - Street 1:30620 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3808
Mailing Address - Country:US
Mailing Address - Phone:248-553-0110
Mailing Address - Fax:248-573-0233
Practice Address - Street 1:31700 W 12 MILE RD STE 103
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-4460
Practice Address - Country:US
Practice Address - Phone:248-553-0110
Practice Address - Fax:248-573-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-20
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010207571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty