Provider Demographics
NPI:1720137953
Name:DILLINGHAM OPTICAL DISPENSARY, INC
Entity type:Organization
Organization Name:DILLINGHAM OPTICAL DISPENSARY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-255-0817
Mailing Address - Street 1:1812 ROSELAWN AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5434
Mailing Address - Country:US
Mailing Address - Phone:318-387-1602
Mailing Address - Fax:318-325-9425
Practice Address - Street 1:1812 ROSELAWN AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5434
Practice Address - Country:US
Practice Address - Phone:318-387-1602
Practice Address - Fax:318-325-9425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1005509Medicaid
LA1005509Medicaid