=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447897186
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFORDABLE SMILES OF HAMMOND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2019
-----------------------------------------------------
Last Update Date | 02/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2804 W THOMAS ST
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70401-2841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-260-8552
-----------------------------------------------------
Fax | 504-602-9885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2804 W. THOMAS STREET
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70401-2841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-260-8552
-----------------------------------------------------
Fax | 504-602-9885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE CREDENTIALING MANAGER
-----------------------------------------------------
Name | MRS. SAMANTHA COATS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 504-609-2599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------