Provider Demographics
NPI:1609259258
Name:GOSSOM, LAURA ALINE (RDH)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ALINE
Last Name:GOSSOM
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-9195
Mailing Address - Country:US
Mailing Address - Phone:270-282-5197
Mailing Address - Fax:
Practice Address - Street 1:5405 BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-9195
Practice Address - Country:US
Practice Address - Phone:270-282-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2979124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist