Provider Demographics
NPI:1124568332
Name:BOYD DDS LLC
Entity Type:Organization
Organization Name:BOYD DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MCKENZY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-425-5356
Mailing Address - Street 1:2042 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2125
Mailing Address - Country:US
Mailing Address - Phone:318-425-5356
Mailing Address - Fax:318-674-2898
Practice Address - Street 1:2042 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2125
Practice Address - Country:US
Practice Address - Phone:318-425-5356
Practice Address - Fax:318-674-2898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1457664906OtherNPI
LA1003124397OtherNPI