Provider Demographics
NPI:1417063561
Name:FONTENOT, TIMOTHY PAUL (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PAUL
Last Name:FONTENOT
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 1:149 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:EUNICE
Mailing Address - State:LA
Mailing Address - Zip Code:70535
Mailing Address - Country:US
Mailing Address - Phone:337-457-1342
Mailing Address - Fax:337-457-1354
Practice Address - Street 1:149 N 3RD ST
Practice Address - Street 2:
Practice Address - City:EUNICE
Practice Address - State:LA
Practice Address - Zip Code:90535
Practice Address - Country:US
Practice Address - Phone:337-457-1342
Practice Address - Fax:337-457-1354
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1836281Medicaid