Provider Demographics
NPI:1679936447
Name:TALLIS, MARK ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:TALLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 ODONOVAN DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-7202
Mailing Address - Country:US
Mailing Address - Phone:225-769-8555
Mailing Address - Fax:225-766-8579
Practice Address - Street 1:5225 ODONOVAN DR
Practice Address - Street 2:SUITE 103
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-7202
Practice Address - Country:US
Practice Address - Phone:225-769-8555
Practice Address - Fax:225-766-8579
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA44561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice