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General NPI Number Information
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NPI Number | 1629642046
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Entity Type | Organization
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Legal Business Name | ORAL & MAXILLOFACIAL SURGERY CENTER OF SOUTH LOUISIANA LLC
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Dates
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Enumeration Date | 05/19/2021
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Last Update Date | 05/19/2021
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Provider Practice Location Address
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Address Line | 363 LAKEVIEW CT
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City | COVINGTON
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State | LA
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Zip | 70433-7515
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Country | US
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Telephone | 985-687-1616
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Fax | 888-920-7457
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Provider Business Mailing Address
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Address Line | 363 LAKEVIEW CT
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City | COVINGTON
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State | LA
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Zip | 70433-7515
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Country | US
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Telephone | 985-687-1616
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Fax | 888-920-7457
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Authorized Official
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Title or Position | OWNER
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Name | JOSHUA BRANDNER
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Credential | DDS, MD
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Telephone | 985-640-2236
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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