Provider Demographics
NPI:1043387160
Name:JACK P NEWELL DDS A PROFESSIOAL CORPORATION
Entity Type:Organization
Organization Name:JACK P NEWELL DDS A PROFESSIOAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:P
Authorized Official - Last Name:NEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-652-2425
Mailing Address - Street 1:179 BELLE TERRE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-3347
Mailing Address - Country:US
Mailing Address - Phone:985-652-2425
Mailing Address - Fax:985-651-7817
Practice Address - Street 1:179 BELLE TERRE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-3347
Practice Address - Country:US
Practice Address - Phone:985-652-2425
Practice Address - Fax:985-651-7817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1830127Medicaid