Provider Demographics
NPI:1043910276
Name:CECOLA, PATRICK RYAN
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:RYAN
Last Name:CECOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 ATHERTON DR
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-5544
Mailing Address - Country:US
Mailing Address - Phone:504-875-8148
Mailing Address - Fax:
Practice Address - Street 1:1291 FLORIDA AVE SW
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-4635
Practice Address - Country:US
Practice Address - Phone:225-664-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA7419122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program