Provider Demographics
NPI:1073234985
Name:BUNKIE DENTISTRY
Entity Type:Organization
Organization Name:BUNKIE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-346-9585
Mailing Address - Street 1:1002 NW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUNKIE
Mailing Address - State:LA
Mailing Address - Zip Code:71322-1519
Mailing Address - Country:US
Mailing Address - Phone:318-346-9585
Mailing Address - Fax:318-346-9596
Practice Address - Street 1:1002 NW MAIN ST
Practice Address - Street 2:
Practice Address - City:BUNKIE
Practice Address - State:LA
Practice Address - Zip Code:71322-1519
Practice Address - Country:US
Practice Address - Phone:318-346-9585
Practice Address - Fax:318-346-9596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3827361Medicaid