Provider Demographics
NPI:1467094789
Name:PALMER AND OBRIEN FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:PALMER AND OBRIEN FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-868-5726
Mailing Address - Street 1:6150 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-2051
Mailing Address - Country:US
Mailing Address - Phone:318-868-5726
Mailing Address - Fax:318-868-7546
Practice Address - Street 1:6150 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2051
Practice Address - Country:US
Practice Address - Phone:318-868-5726
Practice Address - Fax:318-868-7546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA14481Medicaid