Provider Demographics
NPI:1689758096
Name:GONSOULIN, CARL B (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:B
Last Name:GONSOULIN
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 1:126 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2819
Mailing Address - Country:US
Mailing Address - Phone:337-232-0689
Mailing Address - Fax:337-234-7395
Practice Address - Street 1:126 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2819
Practice Address - Country:US
Practice Address - Phone:337-232-0689
Practice Address - Fax:337-234-7395
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry