Provider Demographics
NPI:1669500195
Name:KIM THOMAS JUDICE, DDS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KIM THOMAS JUDICE, DDS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JUDICE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-988-0020
Mailing Address - Street 1:111 NOEL DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-988-0020
Mailing Address - Fax:337-988-0244
Practice Address - Street 1:111 NOEL DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-988-0020
Practice Address - Fax:337-988-0244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA34221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1881805Medicaid