Provider Demographics
NPI:1356613681
Name:C.M. LESTER DDS A PROFESSIONAL DENTAL CORP
Entity type:Organization
Organization Name:C.M. LESTER DDS A PROFESSIONAL DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLEY
Authorized Official - Middle Name:MARION
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-631-0270
Mailing Address - Street 1:4034 HOLLYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-7938
Mailing Address - Country:US
Mailing Address - Phone:318-631-0270
Mailing Address - Fax:318-631-0233
Practice Address - Street 1:4034 HOLLYWOOD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-7938
Practice Address - Country:US
Practice Address - Phone:318-631-0270
Practice Address - Fax:318-631-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1956261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1819565Medicaid