Provider Demographics
NPI:1336558311
Name:DUBOUE DENTAL LLC
Entity Type:Organization
Organization Name:DUBOUE DENTAL LLC
Other - Org Name:HDL DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBOUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-390-2847
Mailing Address - Street 1:PO BOX 30458
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70190-0458
Mailing Address - Country:US
Mailing Address - Phone:504-218-4444
Mailing Address - Fax:504-218-4946
Practice Address - Street 1:633 CARONDELET ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70130-3503
Practice Address - Country:US
Practice Address - Phone:504-218-4444
Practice Address - Fax:504-218-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5635261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1856355Medicaid