Provider Demographics
NPI:1154645117
Name:TA, LAUREN ELIZABETH (DDS,PHD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:TA
Suffix:
Gender:F
Credentials:DDS,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:612-226-3388
Mailing Address - Fax:
Practice Address - Street 1:120 BROADWAY AVE N
Practice Address - Street 2:SUITE B
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-3728
Practice Address - Country:US
Practice Address - Phone:612-226-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist