Provider Demographics
NPI:1679679591
Name:HAYGOOD, GARY STEPHEN (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:STEPHEN
Last Name:HAYGOOD
Suffix:
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 1:1644 CARTER STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373
Mailing Address - Country:US
Mailing Address - Phone:318-336-4211
Mailing Address - Fax:318-336-4212
Practice Address - Street 1:1644 CARTER STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373
Practice Address - Country:US
Practice Address - Phone:318-336-4211
Practice Address - Fax:318-336-4212
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2827122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1828271Medicaid