1407346901 NPI number — LOUISVILLE DENTAL ASSOCIATES LLC

Table of content: (NPI 1407346901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407346901 NPI number — LOUISVILLE DENTAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUISVILLE DENTAL ASSOCIATES 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:
Provider Other Organization Name Type Code:
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:
1407346901
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
186 FAULK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUPORA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39744-5580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-552-6407
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16701 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39339-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-575-8806
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
EAVES
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNTING/OFFICE MANAGER
Authorized Official Telephone Number:
601-575-8806

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com