Provider Demographics
NPI:1801192836
Name:ANTHONY INDOVINA A P D C
Entity Type:Organization
Organization Name:ANTHONY INDOVINA A P D C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:A
Authorized Official - Last Name:INDOVINA
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-340-2401
Mailing Address - Street 1:5132 LAPALCO BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-4268
Mailing Address - Country:US
Mailing Address - Phone:504-340-2401
Mailing Address - Fax:504-340-2423
Practice Address - Street 1:5132 LAPALCO BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-4268
Practice Address - Country:US
Practice Address - Phone:504-340-2401
Practice Address - Fax:504-340-2423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA26501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1826502Medicaid
LA600034OtherUNITED CONCORDIA
LAT19818Medicare UPIN
LA600034OtherUNITED CONCORDIA