Provider Demographics
NPI:1407898158
Name:BAYOU DENTAL, PA
Entity Type:Organization
Organization Name:BAYOU DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-476-5233
Mailing Address - Street 1:4461 BAYOU BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2601
Mailing Address - Country:US
Mailing Address - Phone:850-476-5233
Mailing Address - Fax:
Practice Address - Street 1:4461 BAYOU BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2601
Practice Address - Country:US
Practice Address - Phone:850-476-5233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1808923OtherUNITED CONCORDIA