Provider Demographics
NPI:1255637005
Name:CANAL ST FAMILY DENTISTRY
Entity type:Organization
Organization Name:CANAL ST FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYFIELD
Authorized Official - Middle Name:
Authorized Official - Last Name:LOTTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-482-5444
Mailing Address - Street 1:2752 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-5502
Mailing Address - Country:US
Mailing Address - Phone:504-482-5444
Mailing Address - Fax:504-486-0482
Practice Address - Street 1:2752 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5502
Practice Address - Country:US
Practice Address - Phone:504-482-5444
Practice Address - Fax:504-486-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6011122300000X
LA5706122300000X
LA5042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1850420Medicaid
LA1857068Medicaid
LA1860115Medicaid