Provider Demographics
NPI:1689968695
Name:EDWIN L BERCIER IV DDS
Entity Type:Organization
Organization Name:EDWIN L BERCIER IV DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERCIER
Authorized Official - Suffix:IV
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-334-3581
Mailing Address - Street 1:PO BOX 804
Mailing Address - Street 2:
Mailing Address - City:RAYNE
Mailing Address - State:LA
Mailing Address - Zip Code:70578-0804
Mailing Address - Country:US
Mailing Address - Phone:337-334-3581
Mailing Address - Fax:337-334-2812
Practice Address - Street 1:300 N POLK ST
Practice Address - Street 2:
Practice Address - City:RAYNE
Practice Address - State:LA
Practice Address - Zip Code:70578-6551
Practice Address - Country:US
Practice Address - Phone:337-334-3581
Practice Address - Fax:337-334-2812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5548122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855481Medicaid