Provider Demographics
NPI:1295908028
Name:BOURELL, LAUREN GRAHAM (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:GRAHAM
Last Name:BOURELL
Suffix:
Gender:F
Credentials:DDS, MD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:GRAHAM
Other - Last Name:POSLUSZNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5690 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2736
Mailing Address - Country:US
Mailing Address - Phone:419-479-3939
Mailing Address - Fax:
Practice Address - Street 1:5690 MONROE ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2736
Practice Address - Country:US
Practice Address - Phone:419-479-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-13
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0244101223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery