Provider Demographics
NPI:1639529621
Name:MCVEA DENTAL CENTER
Entity Type:Organization
Organization Name:MCVEA DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:PETTIT
Authorized Official - Last Name:MCVEA
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-839-4138
Mailing Address - Street 1:2016 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-2533
Mailing Address - Country:US
Mailing Address - Phone:985-839-4138
Mailing Address - Fax:985-839-6253
Practice Address - Street 1:2016 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438-2533
Practice Address - Country:US
Practice Address - Phone:985-839-4138
Practice Address - Fax:985-839-6253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4294261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental