Provider Demographics
NPI:1790931293
Name:GUTTORMSEN, LAURA ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANN
Last Name:GUTTORMSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:BROTHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3415 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1622
Mailing Address - Country:US
Mailing Address - Phone:262-654-0267
Mailing Address - Fax:262-654-6939
Practice Address - Street 1:3415 30TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1622
Practice Address - Country:US
Practice Address - Phone:262-654-0267
Practice Address - Fax:262-654-6939
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6307-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist