Provider Demographics
NPI:1184915274
Name:ACADIANA SMILES
Entity type:Organization
Organization Name:ACADIANA SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHONTIZE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-788-0677
Mailing Address - Street 1:608 NORTH AVENUE K
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526
Mailing Address - Country:US
Mailing Address - Phone:337-788-0677
Mailing Address - Fax:337-783-0343
Practice Address - Street 1:608 NORTH AVENUE K
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526
Practice Address - Country:US
Practice Address - Phone:337-788-0677
Practice Address - Fax:337-783-0343
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACADIANA SMILES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5509122300000X
LA5665122300000X
LA4940122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty