Provider Demographics
NPI:1114308582
Name:FERN AVENUE DENTAL CENTER
Entity Type:Organization
Organization Name:FERN AVENUE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:HEILMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-797-1550
Mailing Address - Street 1:7600 FERN AVE
Mailing Address - Street 2:BLDG 1100
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5659
Mailing Address - Country:US
Mailing Address - Phone:318-797-1550
Mailing Address - Fax:
Practice Address - Street 1:7600 FERN AVE
Practice Address - Street 2:BLDG 1100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5659
Practice Address - Country:US
Practice Address - Phone:318-797-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3291122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty