Provider Demographics
NPI:1932290160
Name:FAVALORO, MICHAEL THOMAS (D D S)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:FAVALORO
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 REDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PAULINA
Mailing Address - State:LA
Mailing Address - Zip Code:70763-2320
Mailing Address - Country:US
Mailing Address - Phone:225-869-4811
Mailing Address - Fax:225-869-8868
Practice Address - Street 1:2024 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LUTCHER
Practice Address - State:LA
Practice Address - Zip Code:70071
Practice Address - Country:US
Practice Address - Phone:225-869-8281
Practice Address - Fax:225-869-8868
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA57181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice