Provider Demographics
NPI:1417061276
Name:WASHINGTON, PHILLIP LAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LAYNE
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:LAYNE
Other - Middle Name:
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:309 FRITZ ST
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71343-2506
Mailing Address - Country:US
Mailing Address - Phone:318-339-6657
Mailing Address - Fax:318-339-4405
Practice Address - Street 1:309 FRITZ ST
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71343-2506
Practice Address - Country:US
Practice Address - Phone:318-339-6657
Practice Address - Fax:318-339-4405
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1840173Medicaid