Provider Demographics
NPI:1780737395
Name:MABRY, LARA M (DDS)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:M
Last Name:MABRY
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 1:2601 BONIFACE PKWY
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3106
Mailing Address - Country:US
Mailing Address - Phone:907-337-9448
Mailing Address - Fax:907-337-4123
Practice Address - Street 1:2601 BONIFACE PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3106
Practice Address - Country:US
Practice Address - Phone:907-337-9448
Practice Address - Fax:907-337-4123
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD2601Medicaid