Provider Demographics
NPI:1114634730
Name:LD-NORTHPORT, LLC
Entity Type:Organization
Organization Name:LD-NORTHPORT, LLC
Other - Org Name:NORTH RIVER DENTAL ASSOCIATES, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMIN DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAIGNEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:BA, MA
Authorized Official - Phone:256-783-9468
Mailing Address - Street 1:1100 FAIRFAX PARK
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2809
Mailing Address - Country:US
Mailing Address - Phone:205-752-3506
Mailing Address - Fax:205-752-3570
Practice Address - Street 1:1100 FAIRFAX PARK
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2809
Practice Address - Country:US
Practice Address - Phone:205-752-3506
Practice Address - Fax:205-752-3570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-02
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental