Healthcare Provider Details

I. General information

NPI: 1265706295
Provider Name (Legal Business Name): BAYOU DENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 AIRLINE DR
METAIRIE LA
70003-4330
US

IV. Provider business mailing address

PO BOX 23623
NEW ORLEANS LA
70183-0623
US

V. Phone/Fax

Practice location:
  • Phone: 888-242-1608
  • Fax:
Mailing address:
  • Phone: 888-242-1608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MAHRUFA ISLAM
Title or Position: DENTAL DIRECTOR
Credential: DDS
Phone: 888-242-1608