Provider Demographics
NPI:1609238336
Name:CECIL C GADDIS DDS., A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:CECIL C GADDIS DDS., A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:CLYDE
Authorized Official - Last Name:GADDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-992-6175
Mailing Address - Street 1:P.O. 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1826456Medicaid