Provider Demographics
NPI:1003988239
Name:SHERMAN, EDDY WALLER (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDDY
Middle Name:WALLER
Last Name:SHERMAN
Suffix:
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 191
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71079
Mailing Address - Country:US
Mailing Address - Phone:318-927-2522
Mailing Address - Fax:318-927-1839
Practice Address - Street 1:723 HORSEHOE RD
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:LA
Practice Address - Zip Code:71079
Practice Address - Country:US
Practice Address - Phone:318-927-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA2472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1824721Medicaid