Provider Demographics
NPI:1205978889
Name:MARK A TALLIS DDS APDC
Entity type:Organization
Organization Name:MARK A TALLIS DDS APDC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF S CORP DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:TALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-769-8555
Mailing Address - Street 1:5225 O DONOVAN DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4353
Mailing Address - Country:US
Mailing Address - Phone:225-769-8555
Mailing Address - Fax:225-766-8579
Practice Address - Street 1:5225 O DONOVAN DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4353
Practice Address - Country:US
Practice Address - Phone:225-769-8555
Practice Address - Fax:225-766-8579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA44561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1844560Medicaid