1245494814 NPI number — DUBOUE DENTAL LLC

Table of content: (NPI 1245494814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245494814 NPI number — DUBOUE DENTAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUBOUE DENTAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKETOWN DENTAL
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245494814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30458
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70190-0458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-218-4444
Provider Business Mailing Address Fax Number:
504-218-4204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4134 FLORIDA AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70065-2190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-218-4444
Provider Business Practice Location Address Fax Number:
504-218-4204
Provider Enumeration Date:
07/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DUBOUE
Authorized Official First Name:
JACLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST OWNER
Authorized Official Telephone Number:
504-390-2847

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5635 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1856355 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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