Provider Demographics
NPI:1679541353
Name:LAVILLE, ROBERT RANDOLPH JR
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RANDOLPH
Last Name:LAVILLE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 MATHEWS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5725
Mailing Address - Country:US
Mailing Address - Phone:337-993-3223
Mailing Address - Fax:337-993-2155
Practice Address - Street 1:95 MATHEWS BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5725
Practice Address - Country:US
Practice Address - Phone:337-993-3223
Practice Address - Fax:337-993-2155
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA41981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice