Provider Demographics
NPI:1568162006
Name:REAGAN, LAURYN ELIZABETH MILLER
Entity type:Individual
Prefix:
First Name:LAURYN
Middle Name:ELIZABETH MILLER
Last Name:REAGAN
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 1:1643 SMITH COTTAGE DR
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5065 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-6083
Practice Address - Country:US
Practice Address - Phone:336-714-5726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14403122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program