Provider Demographics
NPI:1154925170
Name:LAURENTIK, LENA
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:LAURENTIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9613 DEDAKER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3112
Mailing Address - Country:US
Mailing Address - Phone:267-902-5570
Mailing Address - Fax:
Practice Address - Street 1:3162 RICHMOND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-5827
Practice Address - Country:US
Practice Address - Phone:215-739-8008
Practice Address - Fax:215-739-8022
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH072197124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist