Basic Information
| Provider Information | |||||||||
| NPI: | 1356588354 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALBANY DENTAL CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALBANY DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29565 MONTEPELIER STREET | ||||||||
| Address2: | ALBANY DENTAL CLINIC | ||||||||
| City: | ALBANY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252090850 | ||||||||
| FaxNumber: | 2252090849 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 SITMAN STREET | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252226059 | ||||||||
| FaxNumber: | 2252226543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2009 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | HITCHEN | ||||||||
| AuthorizedOfficialFirstName: | ROSE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE CLERK | ||||||||
| AuthorizedOfficialTelephone: | 2252090850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALBANY DENTAL CLINIC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1827380 | 05 | LA | MEDICAID | 1303500 | 05 | LA | MEDICAID | 1061115 | 05 | LA | MEDICAID | 1527866 | 05 | LA | MEDICAID | 1394050 | 05 | LA | MEDICAID | 1032107 | 05 | LA | MEDICAID |