Provider Demographics
NPI:1114262649
Name:NATHAN RAY FONTENOT, JR., APDC
Entity Type:Organization
Organization Name:NATHAN RAY FONTENOT, JR., APDC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-824-4963
Mailing Address - Street 1:PO BOX 815
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-0815
Mailing Address - Country:US
Mailing Address - Phone:337-824-4963
Mailing Address - Fax:337-824-4961
Practice Address - Street 1:715 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-5311
Practice Address - Country:US
Practice Address - Phone:337-824-4963
Practice Address - Fax:337-824-4961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3543261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA18354319Medicaid