Provider Demographics
NPI:1639612641
Name:ROUNDTREE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ROUNDTREE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ROUNDTREE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-446-8821
Mailing Address - Street 1:705 PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4303
Mailing Address - Country:US
Mailing Address - Phone:985-446-8821
Mailing Address - Fax:985-447-7420
Practice Address - Street 1:705 PLANTATION RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4303
Practice Address - Country:US
Practice Address - Phone:985-446-8821
Practice Address - Fax:985-447-7420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6023122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty