Provider Demographics
NPI:1093179269
Name:AUDUBON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:AUDUBON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-927-1515
Mailing Address - Street 1:2925 BRAKLEY DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2305
Mailing Address - Country:US
Mailing Address - Phone:225-927-1515
Mailing Address - Fax:225-928-3012
Practice Address - Street 1:2925 BRAKLEY DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2305
Practice Address - Country:US
Practice Address - Phone:225-927-1515
Practice Address - Fax:225-928-3012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5276122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty