Healthcare Provider Details

I. General information

NPI: 1568504868
Provider Name (Legal Business Name): LSUHSC SCHOOL OF DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 FLORIDA AVENUE
NEW ORLEANS LA
70119-2714
US

IV. Provider business mailing address

1100 FLORIDA AVENUE
NEW ORLEANS LA
70119-2714
US

V. Phone/Fax

Practice location:
  • Phone: 504-941-8110
  • Fax: 504-941-8117
Mailing address:
  • Phone: 504-941-8110
  • Fax: 504-941-8112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4618
License Number StateLA

VIII. Authorized Official

Name: DR. JOHN GALLO
Title or Position: ASSISTANT DEAN OF CLINICAL AFFAIRS
Credential: D.D.S.
Phone: 504-941-8110