Provider Demographics
NPI:1255079067
Name:BLACK, LAUREN ELIZABETH (DMD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:BRANSCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:239 CARVER RD APT 3
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-5295
Mailing Address - Country:US
Mailing Address - Phone:603-548-1397
Mailing Address - Fax:
Practice Address - Street 1:107 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-6507
Practice Address - Country:US
Practice Address - Phone:508-477-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAFORTHCOMING1223G0001X
MADN18594111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice