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NPI Code Detail

MEDICARE: MAXILLOFACIAL IMAGING OF BATON ROUGE, LLC

MEDICARE: MAXILLOFACIAL IMAGING OF BATON ROUGE, 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
1261QD0000XDental Clinic/Center3462LA

General Provider Information

NPI Number : 1932490208
Entity Type Code : Organization
Provider Name (Legal Business Name) : MAXILLOFACIAL IMAGING OF BATON ROUGE, LLC
Provider Business Mailing Address
First Line : 7967 OFFICE PARK BLVD
Second Line :
City : BATON ROUGE
State : LA
Zip : 70809-7646
Country : US
Telephone Number : 225-218-0225
Fax Number :
Provider Business Practice Location Address
First Line : 7967 OFFICE PARK BLVD
Second Line :
City : BATON ROUGE
State : LA
Zip : 70809-7646
Country : US
Telephone Number : 225-218-0225
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. DANIEL J RICHARDSON
Credential : DDS
Telephone Number : 225-218-0225
Provider Enumeration Date : 04/21/2011
Last Update Date : 04/21/2011

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