Healthcare Provider Details

I. General information

NPI: 1063865970
Provider Name (Legal Business Name): LDENTAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 402
KAISERSLAUTERN RH-PL
09227
DE

IV. Provider business mailing address

CMR 402
KAISERSLAUTERN RH-PL
09227
DE

V. Phone/Fax

Practice location:
  • Phone: 314-493-4460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON NGUYEN
Title or Position: PULASKI LAB NCOIC
Credential:
Phone: 314-493-4460