Provider Demographics
NPI:1356588354
Name:ALBANY DENTAL CLINIC
Entity type:Organization
Organization Name:ALBANY DENTAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HITCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-209-0850
Mailing Address - Street 1:29565 MONTEPELIER STREET
Mailing Address - Street 2:ALBANY DENTAL CLINIC
Mailing Address - City:ALBANY
Mailing Address - State:LA
Mailing Address - Zip Code:70711
Mailing Address - Country:US
Mailing Address - Phone:225-209-0850
Mailing Address - Fax:225-209-0849
Practice Address - Street 1:490 SITMAN STREET
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:LA
Practice Address - Zip Code:70441
Practice Address - Country:US
Practice Address - Phone:225-222-6059
Practice Address - Fax:225-222-6543
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBANY DENTAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1827380Medicaid
LA1303500Medicaid
LA1061115Medicaid
LA1527866Medicaid
LA1394050Medicaid
LA1032107Medicaid
LA5D432Medicare PIN