Provider Demographics
NPI:1093035081
Name:RESTORATION DENTAL GROUP LLC
Entity Type:Organization
Organization Name:RESTORATION DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF RESTORATION DENTAL GROUP L
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:A
Authorized Official - Last Name:JARVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-797-1181
Mailing Address - Street 1:7607 FERN AVE. SUITE 800
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-797-1181
Mailing Address - Fax:318-797-1180
Practice Address - Street 1:2010 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5306
Practice Address - Country:US
Practice Address - Phone:318-797-1181
Practice Address - Fax:318-797-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3384261QD0000X
LA6042261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental