Provider Demographics
NPI:1932583358
Name:ORAL SURGERY& DENTAL IMPLANT CENTER OF LOUISIANA
Entity Type:Organization
Organization Name:ORAL SURGERY& DENTAL IMPLANT CENTER OF LOUISIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MISURACA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-673-1800
Mailing Address - Street 1:16206 AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4248
Mailing Address - Country:US
Mailing Address - Phone:225-673-1800
Mailing Address - Fax:225-677-9483
Practice Address - Street 1:16206 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-4248
Practice Address - Country:US
Practice Address - Phone:225-766-3300
Practice Address - Fax:225-677-9483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA50511223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty