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General NPI Number Information
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NPI Number | 1689925539
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Entity Type | Organization
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Legal Business Name | NORTHLAKE ORAL AND FACIAL SURGERY LLC
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Dates
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Enumeration Date | 10/01/2012
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Last Update Date | 11/02/2012
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Provider Practice Location Address
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Address Line | 1271 7TH ST
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City | SLIDELL
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State | LA
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Zip | 70458-2041
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Country | US
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Telephone | 985-643-1010
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Fax |
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Provider Business Mailing Address
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Address Line | 1271 7TH ST
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City | SLIDELL
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State | LA
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Zip | 70458-2041
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Country | US
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Telephone | 985-643-1010
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. NATHAN RIAS BROWN
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Credential | MD, DMD
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Telephone | 985-643-1010
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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 | 6298
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License Number State | LA
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