Provider Demographics
NPI:1508923418
Name:EMERY, TERYL K (DO)
Entity Type:Individual
Prefix:
First Name:TERYL
Middle Name:K
Last Name:EMERY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 889
Mailing Address - Street 2:
Mailing Address - City:INNIS
Mailing Address - State:LA
Mailing Address - Zip Code:70747-0889
Mailing Address - Country:US
Mailing Address - Phone:225-492-3775
Mailing Address - Fax:
Practice Address - Street 1:6450 LOUISIANA HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:INNIS
Practice Address - State:LA
Practice Address - Zip Code:70747-0889
Practice Address - Country:US
Practice Address - Phone:225-492-3775
Practice Address - Fax:225-492-3782
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA54001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA185400Medicaid
LA030183OtherSTATE DEA