Provider Demographics
NPI:1033550181
Name:IENNUSA, JOHN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:IENNUSA
Suffix:JR
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 1:2245 11TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-6498
Mailing Address - Country:US
Mailing Address - Phone:985-626-4779
Mailing Address - Fax:
Practice Address - Street 1:2245 11TH ST STE C
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-6498
Practice Address - Country:US
Practice Address - Phone:985-626-4779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA51881223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics