Basic Information
| Provider Information | |||||||||
| NPI: | 1568504868 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LSUHSC SCHOOL OF DENTISTRY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LSU DENTAL SCHOOL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 FLORIDA AVENUE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701192714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049418110 | ||||||||
| FaxNumber: | 5049418112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 FLORIDA AVENUE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701192714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049418110 | ||||||||
| FaxNumber: | 5049418117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 06/16/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GALLO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT DEAN OF CLINICAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 5049418110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.D.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 4618 | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1881031 | 05 | LA | MEDICAID | 1880400 | 05 | LA | MEDICAID | 1846180 | 05 | LA | MEDICAID |