MEDICARE: MARK A TALLIS DDS APDC

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	1223G0001X	General Practice Dentistry	4456	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205978889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK A TALLIS DDS APDC

Provider Business Mailing Address
First Line	:	5225 O DONOVAN DRIVE
Second Line	:	SUITE 103
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-4353
Country	:	US
Telephone Number	:	225-769-8555
Fax Number	:	225-766-8579

Provider Business Practice Location Address
First Line	:	5225 O DONOVAN DRIVE
Second Line	:	SUITE 103
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-4353
Country	:	US
Telephone Number	:	225-769-8555
Fax Number	:	225-766-8579

Authorized Official
Title or Position	:	PRESIDENT OF S CORP DENTIST OWNER
Name	:	DR. MARK ANTHONY TALLIS
Credential	:	DDS
Telephone Number	:	225-769-8555

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	07/09/2013

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