Provider Demographics
NPI:1932490208
Name:MAXILLOFACIAL IMAGING OF BATON ROUGE, LLC
Entity Type:Organization
Organization Name:MAXILLOFACIAL IMAGING OF BATON ROUGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-218-0225
Mailing Address - Street 1:7967 OFFICE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-7646
Mailing Address - Country:US
Mailing Address - Phone:225-218-0225
Mailing Address - Fax:
Practice Address - Street 1:7967 OFFICE PARK BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-7646
Practice Address - Country:US
Practice Address - Phone:225-218-0225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3462261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental