Provider Demographics
NPI:1598801367
Name:GADDIS, CECIL CLYDE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CECIL
Middle Name:CLYDE
Last Name:GADDIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:C
Other - Last Name:GADDIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 891
Mailing Address - Street 2:
Mailing Address - City:JENA
Mailing Address - State:LA
Mailing Address - Zip Code:71342
Mailing Address - Country:US
Mailing Address - Phone:318-992-6175
Mailing Address - Fax:318-992-6197
Practice Address - Street 1:2709 NORTH FIRST STREET
Practice Address - Street 2:
Practice Address - City:JENA
Practice Address - State:LA
Practice Address - Zip Code:71342
Practice Address - Country:US
Practice Address - Phone:318-992-6175
Practice Address - Fax:318-992-6197
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1826456Medicaid