Provider Demographics
NPI:1306279039
Name:IENNUSA ORTHODONTICS, INC.
Entity type:Organization
Organization Name:IENNUSA ORTHODONTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:IENNUSA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-626-4779
Mailing Address - Street 1:2245 11TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-6498
Mailing Address - Country:US
Mailing Address - Phone:985-626-4779
Mailing Address - Fax:
Practice Address - Street 1:2245 11TH ST STE C
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-6498
Practice Address - Country:US
Practice Address - Phone:985-626-4779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5188261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental