Provider Demographics
NPI:1689607517
Name:ATKINS, CARROLL BUCK JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:BUCK
Last Name:ATKINS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5935
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5935
Mailing Address - Country:US
Mailing Address - Phone:318-797-8038
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:# 160
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:318-841-4795
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA26791223G0001X
LA9568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered183500000XPharmacy Service ProvidersPharmacist