Provider Demographics
NPI:1497006522
Name:ADH-PORT VINCENT, LLC
Entity Type:Organization
Organization Name:ADH-PORT VINCENT, LLC
Other - Org Name:PORT VINCENT DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:SUADI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-753-5885
Mailing Address - Street 1:15420 S HARRELLS FERRY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2933
Mailing Address - Country:US
Mailing Address - Phone:225-753-5885
Mailing Address - Fax:225-753-5908
Practice Address - Street 1:18335 LA HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PORT VINCENT
Practice Address - State:LA
Practice Address - Zip Code:70726-8025
Practice Address - Country:US
Practice Address - Phone:225-698-9510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA48181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty