Provider Demographics
NPI:1013770189
Name:MANDEVILLE DENTAL ASSOCIATES LLC
Entity type:Organization
Organization Name:MANDEVILLE DENTAL ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:POYADOU
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-266-2000
Mailing Address - Street 1:100 TYLER SQ STE 4
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-3060
Mailing Address - Country:US
Mailing Address - Phone:985-266-2000
Mailing Address - Fax:985-266-2002
Practice Address - Street 1:1510 W CAUSEWAY APPROACH STE B
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3022
Practice Address - Country:US
Practice Address - Phone:985-231-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty