Provider Demographics
NPI:1295152254
Name:LAUDERDALE DENTAL LLC
Entity type:Organization
Organization Name:LAUDERDALE DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DMD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUDERDALE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:315-454-6000
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6783 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-3254
Practice Address - Country:US
Practice Address - Phone:706-321-3909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA138921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty