Provider Demographics
NPI:1780608620
Name:LAUDENBACH, JAY B (DMD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:B
Last Name:LAUDENBACH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 IDRIS RD
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1611
Mailing Address - Country:US
Mailing Address - Phone:610-668-2178
Mailing Address - Fax:
Practice Address - Street 1:1520 LOCUST ST
Practice Address - Street 2:SUITE 600
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4403
Practice Address - Country:US
Practice Address - Phone:215-985-4337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035409122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223P0300XDental ProvidersDentistPeriodontics