Provider Demographics
NPI:1154543288
Name:LSU HEALTH SCIENCES CENTER LSU FACULTY DENTAL PRACTICE
Entity type:Organization
Organization Name:LSU HEALTH SCIENCES CENTER LSU FACULTY DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SPEEGLE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:504-941-8119
Mailing Address - Street 1:1100 FLORIDA AVE
Mailing Address - Street 2:BOX 131
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-2714
Mailing Address - Country:US
Mailing Address - Phone:504-619-8721
Mailing Address - Fax:504-941-8001
Practice Address - Street 1:1100 FLORIDA AVE
Practice Address - Street 2:BOX 131
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-2714
Practice Address - Country:US
Practice Address - Phone:504-619-8721
Practice Address - Fax:504-941-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA50031223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAA8122OtherBLUE CROSS
LA1952702Medicaid
LAA8122OtherBLUE CROSS