Provider Demographics
NPI:1073794731
Name:OUR LADY OF THE LAKE ORAL SURGERY CLINIC
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE ORAL SURGERY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAMSEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:225-765-8967
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 1004
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 1004
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-8551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE LAKE HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty