Provider Demographics
NPI:1881144236
Name:WASEK-THROM, LAURA (DMD,MPH)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WASEK-THROM
Suffix:
Gender:F
Credentials:DMD,MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 RANIER CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-5028
Mailing Address - Country:US
Mailing Address - Phone:231-392-3553
Mailing Address - Fax:
Practice Address - Street 1:5720 LOCKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5020
Practice Address - Country:US
Practice Address - Phone:817-737-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010215201223G0001X
TX358801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice