Provider Demographics
NPI:1326290735
Name:FUNKE, LAURA JANE (DMD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JANE
Last Name:FUNKE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 W. NATIONAL AVE.
Mailing Address - Street 2:
Mailing Address - City:W. MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214
Mailing Address - Country:US
Mailing Address - Phone:414-645-7777
Mailing Address - Fax:414-645-5360
Practice Address - Street 1:2551 RIVER PARK PLZ STE 210
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-0691
Practice Address - Country:US
Practice Address - Phone:174-294-4448
Practice Address - Fax:817-732-4420
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6306015122300000X
TX238731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist