Healthcare Provider Details

I. General information

NPI: 1184787921
Provider Name (Legal Business Name): ANTHONY A. INDOVINA SR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5132 LAPALCO BLVD 2ND FLOOR
MARRERO LA
70072-4238
US

IV. Provider business mailing address

5132 LAPALCO BLVD 2ND FLOOR
MARRERO LA
70072-4238
US

V. Phone/Fax

Practice location:
  • Phone: 504-340-2401
  • Fax: 504-340-2423
Mailing address:
  • Phone: 504-340-2401
  • Fax: 504-340-2423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2650
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: