Provider Demographics
NPI:1851779623
Name:DR. MICHAEL GAMBILL AND DR. DAVID GLASS LLC
Entity Type:Organization
Organization Name:DR. MICHAEL GAMBILL AND DR. DAVID GLASS LLC
Other - Org Name:PEDIATRIC DENTISTRY OF SHREVEPORT-BOSSIER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-742-9333
Mailing Address - Street 1:2285 BENTON RD
Mailing Address - Street 2:SUITE C-100
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-7933
Mailing Address - Country:US
Mailing Address - Phone:318-742-9333
Mailing Address - Fax:318-742-1512
Practice Address - Street 1:2285 BENTON RD
Practice Address - Street 2:SUITE C-100
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-7933
Practice Address - Country:US
Practice Address - Phone:318-742-9333
Practice Address - Fax:318-742-1512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA64221223P0221X
LA22171223P0221X
LA64851223P0221X
LA62241223P0221X
LA65321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1822175Medicaid
LA1864226Medicaid
LA1864854Medicaid