Provider Demographics
NPI:1568504868
Name:LSUHSC SCHOOL OF DENTISTRY
Entity Type:Organization
Organization Name:LSUHSC SCHOOL OF DENTISTRY
Other - Org Name:LSU DENTAL SCHOOL
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT DEAN OF CLINICAL AFFAIRS
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-941-8110
Mailing Address - Street 1:1100 FLORIDA AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-2714
Mailing Address - Country:US
Mailing Address - Phone:504-941-8110
Mailing Address - Fax:504-941-8112
Practice Address - Street 1:1100 FLORIDA AVENUE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-2714
Practice Address - Country:US
Practice Address - Phone:504-941-8110
Practice Address - Fax:504-941-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4618122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1881031Medicaid
LA1880400Medicaid
LA1846180Medicaid