Provider Demographics
NPI:1023088085
Name:HOUSWORTH, LAURIE ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:ANN
Last Name:HOUSWORTH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 SE 165TH MULBERRY LANE
Mailing Address - Street 2:THE VILLAGES VA OUTPATIENT CLINIC
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162
Mailing Address - Country:US
Mailing Address - Phone:352-674-5000
Mailing Address - Fax:
Practice Address - Street 1:8900 SE 165TH MULBERRY LANE
Practice Address - Street 2:THE VILLAGES VA OUTPATIENT CLINIC
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162
Practice Address - Country:US
Practice Address - Phone:352-674-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0125091223G0001X
FLHAD71223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0767131-00Medicaid