Provider Demographics
NPI:1598302994
Name:DENT, CEDRIC LEON JR
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:LEON
Last Name:DENT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 COMMERCIAL DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5954
Mailing Address - Country:US
Mailing Address - Phone:985-662-3799
Mailing Address - Fax:985-662-3829
Practice Address - Street 1:1102 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5954
Practice Address - Country:US
Practice Address - Phone:985-662-3799
Practice Address - Fax:985-662-3829
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366728420Medicaid