Provider Demographics
NPI:1508392069
Name:DEEP SOUTH FAMILY DENTISTRY
Entity Type:Organization
Organization Name:DEEP SOUTH FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-386-9936
Mailing Address - Street 1:1160 HWY 51 NORTH
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454
Mailing Address - Country:US
Mailing Address - Phone:985-386-9936
Mailing Address - Fax:
Practice Address - Street 1:1160 HWY 51 NORTH
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454
Practice Address - Country:US
Practice Address - Phone:985-386-9936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5258122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty