Provider Demographics
NPI:1942442769
Name:LOUISIANA DENTAL GROUP, INC,
Entity Type:Organization
Organization Name:LOUISIANA DENTAL GROUP, INC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THERIOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-258-4939
Mailing Address - Street 1:4702 JOHNSTON ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-4501
Mailing Address - Country:US
Mailing Address - Phone:337-984-3408
Mailing Address - Fax:337-984-9898
Practice Address - Street 1:4702 JOHNSTON ST
Practice Address - Street 2:SUITE D
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-4501
Practice Address - Country:US
Practice Address - Phone:337-984-3408
Practice Address - Fax:337-984-9898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA54291223G0001X
LA57391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1854298Medicaid
LA1334855Medicaid
LA1335240Medicaid