Provider Demographics
NPI:1689768897
Name:MOUSER, KENNETH WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:MOUSER
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 1:9091 ELLERBE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6738
Mailing Address - Country:US
Mailing Address - Phone:318-865-7005
Mailing Address - Fax:318-865-7088
Practice Address - Street 1:9091 ELLERBE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6738
Practice Address - Country:US
Practice Address - Phone:318-865-7005
Practice Address - Fax:318-865-7088
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA42091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice