Provider Demographics
NPI:1215450531
Name:LAURA A GUTTORMSEN DDS LLC
Entity type:Organization
Organization Name:LAURA A GUTTORMSEN DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENIST/OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUTTORMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-945-7970
Mailing Address - Street 1:6402 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5028
Mailing Address - Country:US
Mailing Address - Phone:262-654-2261
Mailing Address - Fax:262-657-6933
Practice Address - Street 1:6402 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5028
Practice Address - Country:US
Practice Address - Phone:262-654-2261
Practice Address - Fax:262-657-6933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6307-15122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty