Provider Demographics
NPI:1992115919
Name:SOUTHERN DENTAL CARE, LLC
Entity type:Organization
Organization Name:SOUTHERN DENTAL CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:ADDISON
Authorized Official - Last Name:ANDREOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-347-1014
Mailing Address - Street 1:35330 BOND DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-6136
Mailing Address - Country:US
Mailing Address - Phone:985-707-9122
Mailing Address - Fax:
Practice Address - Street 1:7301 WESTBANK EXPY
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-2448
Practice Address - Country:US
Practice Address - Phone:504-347-1014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA63501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1863505Medicaid