Provider Demographics
NPI:1336201417
Name:LEBLANC, VINTAGE LEIGH (DDS)
Entity Type:Individual
Prefix:DR
First Name:VINTAGE
Middle Name:LEIGH
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:VINTAGE
Other - Middle Name:LEIGH
Other - Last Name:DELAHOUSSAYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:107 REGENCY SQ
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4221
Mailing Address - Country:US
Mailing Address - Phone:337-739-3396
Mailing Address - Fax:337-234-8723
Practice Address - Street 1:1144 COOLIDGE BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-234-8788
Practice Address - Fax:337-256-5150
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855235Medicaid