Provider Demographics
NPI:1487674909
Name:PEMBERTON, NANCY JEAN (DDS)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:JEAN
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MONSANTO AVE
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070-2149
Mailing Address - Country:US
Mailing Address - Phone:985-785-0620
Mailing Address - Fax:985-785-0611
Practice Address - Street 1:111 MONSANTO AVE
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-2149
Practice Address - Country:US
Practice Address - Phone:985-785-0620
Practice Address - Fax:985-785-0611
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4504122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA184504 3Medicaid
899161OtherUNITED CONCORDIA
A2170OtherBLUE CROSS BLUE SHIELD