Provider Demographics
NPI:1205120102
Name:CHANNING, LAURA (DDS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:CHANNING
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:SCHMITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:15910 W COMPANY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-5320
Mailing Address - Country:US
Mailing Address - Phone:715-934-2224
Mailing Address - Fax:715-934-5740
Practice Address - Street 1:15910 W COMPANY LAKE RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5320
Practice Address - Country:US
Practice Address - Phone:715-934-2224
Practice Address - Fax:715-934-5740
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223G0001X1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1205120102Medicaid