Provider Demographics
NPI:1225369242
Name:LOUISIANA DENTAL PROFESSIONALS, DONOVAN DRONET, DDS, A PROFESSIONAL DE
Entity Type:Organization
Organization Name:LOUISIANA DENTAL PROFESSIONALS, DONOVAN DRONET, DDS, A PROFESSIONAL DE
Other - Org Name:PELICAN PARK DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8426
Mailing Address - Street 1:4040 LONESOME RD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448
Mailing Address - Country:US
Mailing Address - Phone:985-626-5030
Mailing Address - Fax:985-626-5018
Practice Address - Street 1:4040 LONESOME RD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448
Practice Address - Country:US
Practice Address - Phone:985-626-5030
Practice Address - Fax:985-626-5018
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUISIANA DENTAL PROFESSIONALS, DONOVAN DRONET, DDS, A PROFESSIONAL DE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-15
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty