Provider Demographics
NPI:1407824204
Name:HORNSBY, CHARLES GRADY (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GRADY
Last Name:HORNSBY
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 1:5227 FLANDERS DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-9169
Mailing Address - Country:US
Mailing Address - Phone:225-769-3600
Mailing Address - Fax:225-767-3275
Practice Address - Street 1:5227 FLANDERS DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-9169
Practice Address - Country:US
Practice Address - Phone:225-769-3600
Practice Address - Fax:225-767-3275
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA27191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAF2281OtherBCBS OF LA
LA1827193Medicaid
LA1827193Medicaid
LA58448Medicare ID - Type Unspecified