Provider Demographics
NPI:1598209207
Name:LAKE AREA DENTISTRY-DEQUINCY, LLC
Entity Type:Organization
Organization Name:LAKE AREA DENTISTRY-DEQUINCY, LLC
Other - Org Name:LAKE AREA DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HENNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-786-6221
Mailing Address - Street 1:824 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DEQUINCY
Mailing Address - State:LA
Mailing Address - Zip Code:70633
Mailing Address - Country:US
Mailing Address - Phone:337-786-6221
Mailing Address - Fax:
Practice Address - Street 1:824 W 4TH ST
Practice Address - Street 2:
Practice Address - City:DEQUINCY
Practice Address - State:LA
Practice Address - Zip Code:70633
Practice Address - Country:US
Practice Address - Phone:337-786-6221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA-6269261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental