Healthcare Provider Details

I. General information

NPI: 1992051007
Provider Name (Legal Business Name): ASCENSION ORAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 AIRLINE HWY SUITE A
PRAIRIEVILLE LA
70769-4272
US

IV. Provider business mailing address

16260 AIRLINE HWY SUITE A
PRAIRIEVILLE LA
70769-4272
US

V. Phone/Fax

Practice location:
  • Phone: 225-744-2660
  • Fax: 225-744-2666
Mailing address:
  • Phone: 225-744-2660
  • Fax: 225-744-2666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6296
License Number StateLA

VIII. Authorized Official

Name: DR. MARK RICHARD JOSEPHS
Title or Position: ORAL AND MAXILLOFACIAL SURGEON
Credential: DMD
Phone: 225-744-2660