Provider Demographics
NPI:1811376080
Name:LAUR, BRIGITTE
Entity Type:Individual
Prefix:MS
First Name:BRIGITTE
Middle Name:
Last Name:LAUR
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 1:404 W SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-1223
Mailing Address - Country:US
Mailing Address - Phone:269-792-0144
Mailing Address - Fax:
Practice Address - Street 1:404 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1223
Practice Address - Country:US
Practice Address - Phone:269-792-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902015023124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174963375Medicaid