Provider Demographics
NPI:1336597186
Name:BLAICH, LAUREN E (DDS)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
Last Name:BLAICH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 KANELL BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3041
Mailing Address - Country:US
Mailing Address - Phone:573-785-0111
Mailing Address - Fax:573-785-3840
Practice Address - Street 1:2700 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3041
Practice Address - Country:US
Practice Address - Phone:573-785-0111
Practice Address - Fax:573-785-3840
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160173961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice