Provider Demographics
NPI:1467111203
Name:ROOTS PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:ROOTS PEDIATRIC DENTISTRY, LLC
Other - Org Name:ADRIENNE A. REVIERE, DDS. LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-234-2349
Mailing Address - Street 1:185 S BEADLE RD BLDG 1
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4287
Mailing Address - Country:US
Mailing Address - Phone:337-234-2349
Mailing Address - Fax:337-261-1785
Practice Address - Street 1:185 S BEADLE RD BLDG 1
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4287
Practice Address - Country:US
Practice Address - Phone:337-234-2349
Practice Address - Fax:337-261-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2870858Medicaid
LA6569OtherDENTIST
LA1865699Medicaid
LA7085OtherDENTIST