Healthcare Provider Details

I. General information

NPI: 1922266576
Provider Name (Legal Business Name): NORTHLAKE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 N CAUSEWAY BLVD
MANDEVILLE LA
70471-3116
US

IV. Provider business mailing address

2030 N CAUSEWAY BLVD
MANDEVILLE LA
70471-3116
US

V. Phone/Fax

Practice location:
  • Phone: 985-626-3338
  • Fax: 985-626-3318
Mailing address:
  • Phone: 985-626-3338
  • Fax: 985-626-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PATRICK SHANNON ALLISON
Title or Position: OWNER
Credential: DDS
Phone: 985-626-3338