Provider Demographics
NPI:1881839231
Name:J & J DENTAL
Entity Type:Organization
Organization Name:J & J DENTAL
Other - Org Name:PEACH TREE DENTAL MONROE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:HENTON
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:318-325-4220
Mailing Address - Street 1:2024 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3609
Mailing Address - Country:US
Mailing Address - Phone:318-325-4220
Mailing Address - Fax:318-323-4362
Practice Address - Street 1:2024 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3609
Practice Address - Country:US
Practice Address - Phone:318-325-4220
Practice Address - Fax:318-323-4362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA52051223G0001X
LA58431223G0001X
LA58071223G0001X
LA35861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty