Provider Demographics
NPI:1487859567
Name:SLAY, AMELIA JOAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:JOAN
Last Name:SLAY
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 1:1297 SHREVEPORT BARKSDALE HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2405
Mailing Address - Country:US
Mailing Address - Phone:318-865-8725
Mailing Address - Fax:318-869-4725
Practice Address - Street 1:1297 SHREVEPORT BARKSDALE HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2405
Practice Address - Country:US
Practice Address - Phone:318-865-8725
Practice Address - Fax:318-869-4725
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0135691223G0001X
LA59401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice