Provider Demographics
NPI:1194272203
Name:LDENTAC
Entity type:Organization
Organization Name:LDENTAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. LAB TECH
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-493-4460
Mailing Address - Street 1:12A IN DEN BRUNNENWEISER
Mailing Address - Street 2:
Mailing Address - City:MOCKENBACH
Mailing Address - State:RP
Mailing Address - Zip Code:68676
Mailing Address - Country:DE
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CMR 402
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09227
Practice Address - Country:US
Practice Address - Phone:314-493-4460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory