MEDICARE: DR. MARK ANTHONY TALLIS D.D.S.

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

General Provider Information

NPI Number	:	1679936447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK ANTHONY TALLIS D.D.S.

Provider Business Mailing Address
First Line	:	5225 ODONOVAN DR
Second Line	:	SUITE 103
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-7202
Country	:	US
Telephone Number	:	225-769-8555
Fax Number	:	225-766-8579

Provider Business Practice Location Address
First Line	:	5225 ODONOVAN DR
Second Line	:	SUITE 103
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-7202
Country	:	US
Telephone Number	:	225-769-8555
Fax Number	:	225-766-8579

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2016
Last Update Date	:	03/30/2016

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