Provider Demographics
NPI:1780214866
Name:PONCHARTRAIN DENTAL, LLC
Entity Type:Organization
Organization Name:PONCHARTRAIN DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:RALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-845-8244
Mailing Address - Street 1:4890 HIGHWAY 22 STE B
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-6751
Mailing Address - Country:US
Mailing Address - Phone:985-845-8244
Mailing Address - Fax:985-845-8255
Practice Address - Street 1:4890 HIGHWAY 22 STE B
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-6751
Practice Address - Country:US
Practice Address - Phone:985-845-8244
Practice Address - Fax:985-845-8255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental