Provider Demographics
NPI:1578736690
Name:MOBILE DENTAL PROGRAM
Entity Type:Organization
Organization Name:MOBILE DENTAL PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT/FISCAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GERMAINE
Authorized Official - Middle Name:TILLAGE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-658-2501
Mailing Address - Street 1:1300 PERDIDO ST
Mailing Address - Street 2:ROOM 8W03B
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2125
Mailing Address - Country:US
Mailing Address - Phone:504-658-2584
Mailing Address - Fax:
Practice Address - Street 1:1300 PERDIDO ST
Practice Address - Street 2:ROOM 8W03B
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2125
Practice Address - Country:US
Practice Address - Phone:504-658-2584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF NEW ORLEANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1880051Medicaid