Provider Demographics
NPI:1346396587
Name:BOUZIGARD, JOHNNY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:J
Last Name:BOUZIGARD
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 1:15384 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CUT OFF
Mailing Address - State:LA
Mailing Address - Zip Code:70345-3411
Mailing Address - Country:US
Mailing Address - Phone:985-632-4394
Mailing Address - Fax:985-632-2894
Practice Address - Street 1:15384 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CUT OFF
Practice Address - State:LA
Practice Address - Zip Code:70345-3411
Practice Address - Country:US
Practice Address - Phone:985-632-4394
Practice Address - Fax:985-632-2894
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1820423Medicaid
LA2042OtherSTATE LICENSE NUMBER