MEDICARE: MAXILLOFACIAL IMAGING OF BATON ROUGE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	3462	LA

General Provider Information

NPI Number	:	1932490208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAXILLOFACIAL IMAGING OF BATON ROUGE, LLC

Provider Business Mailing Address
First Line	:	7967 OFFICE PARK BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-7646
Country	:	US
Telephone Number	:	225-218-0225
Fax Number	:

Provider Business Practice Location Address
First Line	:	7967 OFFICE PARK BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-7646
Country	:	US
Telephone Number	:	225-218-0225
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DANIEL J RICHARDSON
Credential	:	DDS
Telephone Number	:	225-218-0225

Provider Enumeration Date	:	04/21/2011
Last Update Date	:	04/21/2011

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