Provider Demographics
NPI:1720483837
Name:MOTT IMAGING, LLC
Entity Type:Organization
Organization Name:MOTT IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-424-7113
Mailing Address - Street 1:631 MILAM ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3534
Mailing Address - Country:US
Mailing Address - Phone:318-424-7113
Mailing Address - Fax:317-424-7350
Practice Address - Street 1:631 MILAM
Practice Address - Street 2:SUITE 101
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-424-7113
Practice Address - Fax:318-424-7350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4247122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty