Healthcare Provider Details

I. General information

NPI: 1154543288
Provider Name (Legal Business Name): LSU HEALTH SCIENCES CENTER LSU FACULTY DENTAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 FLORIDA AVE BOX 131
NEW ORLEANS LA
70119-2714
US

IV. Provider business mailing address

1100 FLORIDA AVE BOX 131
NEW ORLEANS LA
70119-2714
US

V. Phone/Fax

Practice location:
  • Phone: 504-619-8721
  • Fax: 504-941-8001
Mailing address:
  • Phone: 504-619-8721
  • Fax: 504-941-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number5003
License Number StateLA

VIII. Authorized Official

Name: MRS. SUE H. SPEEGLE
Title or Position: PRACTICE MANAGER
Credential: CPA
Phone: 504-941-8119