Basic Information
| Provider Information | |||||||||
| NPI: | 1427351576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNYDER | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRABOWSKI | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.D.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3949 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976034746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5418821670 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 CHILOQUIN BLVD. | ||||||||
| Address2: | |||||||||
| City: | CHILOQUIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5417832028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2010 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D12856 | MN | N | Dental Providers | Dentist | 122300000X | D9850 | OR | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 500655535 | 05 | OR | MEDICAID |