Provider Demographics
NPI:1124181235
Name:DESOTO, BILLY MELVIN (DDS)
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:MELVIN
Last Name:DESOTO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 SOUTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2120
Mailing Address - Country:US
Mailing Address - Phone:318-686-6411
Mailing Address - Fax:318-686-5187
Practice Address - Street 1:2515 SOUTHSIDE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2120
Practice Address - Country:US
Practice Address - Phone:318-686-6411
Practice Address - Fax:318-686-5187
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics