Provider Demographics
NPI:1689925539
Name:NORTHLAKE ORAL AND FACIAL SURGERY LLC
Entity Type:Organization
Organization Name:NORTHLAKE ORAL AND FACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:RIAS
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DMD
Authorized Official - Phone:985-643-1010
Mailing Address - Street 1:1271 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2041
Mailing Address - Country:US
Mailing Address - Phone:985-643-1010
Mailing Address - Fax:
Practice Address - Street 1:1271 7TH ST
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2041
Practice Address - Country:US
Practice Address - Phone:985-643-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA62981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty