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General NPI Number Information
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NPI Number | 1922266576
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Entity Type | Organization
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Legal Business Name | NORTHLAKE DENTAL LLC
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Dates
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Enumeration Date | 05/30/2008
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Last Update Date | 07/31/2020
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Provider Practice Location Address
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Address Line | 2030 N CAUSEWAY BLVD
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City | MANDEVILLE
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State | LA
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Zip | 70471-3116
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Country | US
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Telephone | 985-626-3338
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Fax | 985-626-3318
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Provider Business Mailing Address
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Address Line | 2030 N CAUSEWAY BLVD
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City | MANDEVILLE
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State | LA
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Zip | 70471-3116
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Country | US
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Telephone | 985-626-3338
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Fax | 985-626-3318
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Authorized Official
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Title or Position | OWNER
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Name | DR. PATRICK SHANNON ALLISON
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Credential | DDS
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Telephone | 985-626-3338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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