Provider Demographics
NPI:1003943135
Name:PEDIATRIC DENTIST, PDC
Entity Type:Organization
Organization Name:PEDIATRIC DENTIST, PDC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-669-8679
Mailing Address - Street 1:2201 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002
Mailing Address - Country:US
Mailing Address - Phone:504-831-2120
Mailing Address - Fax:504-831-2310
Practice Address - Street 1:2201 VETERANS MEMORIAL BLVD
Practice Address - Street 2:SUITE 306
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002
Practice Address - Country:US
Practice Address - Phone:504-831-2120
Practice Address - Fax:504-831-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA51321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1851329Medicaid