Provider Demographics
NPI:1275067282
Name:SMART DENTAL CARE PRAIRIEVILLE, LLC
Entity Type:Organization
Organization Name:SMART DENTAL CARE PRAIRIEVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:EMMETT
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-677-9999
Mailing Address - Street 1:37290 OLD PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3764
Mailing Address - Country:US
Mailing Address - Phone:225-677-9999
Mailing Address - Fax:225-677-9993
Practice Address - Street 1:37290 OLD PERKINS RD
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3764
Practice Address - Country:US
Practice Address - Phone:225-677-9999
Practice Address - Fax:225-677-9993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA54911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty