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General NPI Number Information
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NPI Number | 1932759271
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Entity Type | Organization
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Legal Business Name | LOUISIANA ORAL & IMPLANT SURGERY
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Dates
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Enumeration Date | 09/18/2019
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Last Update Date | 12/23/2019
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Provider Practice Location Address
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Address Line | 4720 LAKE STREET
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City | LAKE CHARLES
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State | LA
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Zip | 70605
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Country | US
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Telephone | 337-888-4771
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Fax | 337-888-4772
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Provider Business Mailing Address
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Address Line | 4720 LAKE STREET
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City | LAKE CHARLES
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State | LA
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Zip | 70605
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Country | US
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Telephone | 337-888-4771
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Fax | 337-888-4772
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Authorized Official
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Title or Position | ORAL AND MAXILLOFACIAL SURGEON/OWNE
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Name | NICKOLAS MASKAS
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Credential | DDS, MD
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Telephone | 337-888-4771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number |
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License Number State |
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