Healthcare Provider Details

I. General information

NPI: 1194272203
Provider Name (Legal Business Name): LDENTAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 402
APO AE
09227
US

IV. Provider business mailing address

12A IN DEN BRUNNENWEISER
MOCKENBACH RP
68676
DE

V. Phone/Fax

Practice location:
  • Phone: 314-493-4460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number
License Number State

VIII. Authorized Official

Name: EDDIE ANDERSON
Title or Position: SR. LAB TECH
Credential:
Phone: 314-493-4460