Provider Demographics
NPI:1578777108
Name:CHARLIE P. ILAWAN, DDS, APDC
Entity Type:Organization
Organization Name:CHARLIE P. ILAWAN, DDS, APDC
Other - Org Name:FAMILY DENTISTRY OF BOGALUSA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:ILAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-735-7372
Mailing Address - Street 1:400 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3323
Mailing Address - Country:US
Mailing Address - Phone:985-735-7372
Mailing Address - Fax:985-732-5944
Practice Address - Street 1:400 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3323
Practice Address - Country:US
Practice Address - Phone:985-735-7372
Practice Address - Fax:985-732-5944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA43611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1880949Medicaid
MS09014606Medicaid
LA971021OtherUNITED CONCORDIA