Provider Demographics
NPI:1659425064
Name:LANDRY, CARROLL JOHN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:JOHN
Last Name:LANDRY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5421 LAPALCO BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-4152
Mailing Address - Country:US
Mailing Address - Phone:504-348-0080
Mailing Address - Fax:504-348-0023
Practice Address - Street 1:5421 LAPALCO BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-4152
Practice Address - Country:US
Practice Address - Phone:504-348-0080
Practice Address - Fax:504-348-0023
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA37071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice