Provider Demographics
NPI:1225379480
Name:SENIOR DENTAL CARE OF LOUISIANA
Entity Type:Organization
Organization Name:SENIOR DENTAL CARE OF LOUISIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-398-4500
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-0367
Mailing Address - Country:US
Mailing Address - Phone:850-398-4500
Mailing Address - Fax:
Practice Address - Street 1:16119 STATE ROAD 71 S
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-2810
Practice Address - Country:US
Practice Address - Phone:850-398-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty