Provider Demographics
NPI:1821095308
Name:VINSON, LAQUIA (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:LAQUIA
Middle Name:
Last Name:VINSON
Suffix:
Gender:F
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 RILEY HOSPITAL DR
Mailing Address - Street 2:SUITE 4205
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5109
Mailing Address - Country:US
Mailing Address - Phone:317-944-9604
Mailing Address - Fax:317-948-0760
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:SUITE 4205
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-9604
Practice Address - Fax:317-948-0760
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010589A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200515490Medicaid