Provider Demographics
NPI:1003919374
Name:BERCIER, EDWIN L IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:L
Last Name:BERCIER
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 804
Mailing Address - Street 2:507 S ARENAS ST
Mailing Address - City:RAYNE
Mailing Address - State:LA
Mailing Address - Zip Code:70578-0804
Mailing Address - Country:US
Mailing Address - Phone:337-334-3581
Mailing Address - Fax:
Practice Address - Street 1:300 N POLK ST
Practice Address - Street 2:
Practice Address - City:RAYNE
Practice Address - State:LA
Practice Address - Zip Code:70578-6551
Practice Address - Country:US
Practice Address - Phone:337-334-3581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855481Medicaid