MEDICARE: PLANTATION ROAD DENTAL CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	3800	LA

General Provider Information

NPI Number	:	1083087043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLANTATION ROAD DENTAL CARE LLC

Provider Business Mailing Address
First Line	:	103 PLANTATION RD
Second Line	:
City	:	DESTREHAN
State	:	LA
Zip	:	70047-3016
Country	:	US
Telephone Number	:	985-764-1148
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 PLANTATION RD
Second Line	:
City	:	DESTREHAN
State	:	LA
Zip	:	70047-3016
Country	:	US
Telephone Number	:	985-764-1148
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	MELANIE J ANDREWS
Credential	:	DDS
Telephone Number	:	985-764-1148

Provider Enumeration Date	:	11/12/2015
Last Update Date	:	11/12/2015

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