Provider Demographics
NPI:1043760804
Name:MARLON HANLEY, DDS, A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:MARLON HANLEY, DDS, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLON
Authorized Official - Middle Name:
Authorized Official - Last Name:HANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-868-9343
Mailing Address - Street 1:1539 MARTIN LUTHER KING JR BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2442
Mailing Address - Country:US
Mailing Address - Phone:985-868-9343
Mailing Address - Fax:
Practice Address - Street 1:1539 MARTIN LUTHER KING JR BLVD STE 112
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2442
Practice Address - Country:US
Practice Address - Phone:985-868-9343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6656122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty