Provider Demographics
NPI:1376024810
Name:LOUISIANA FAMILY DENTAL
Entity type:Organization
Organization Name:LOUISIANA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DRAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLIVETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-402-4004
Mailing Address - Street 1:11331 OLD HAMMOND HWY STE BC&D
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8461
Mailing Address - Country:US
Mailing Address - Phone:225-256-6386
Mailing Address - Fax:
Practice Address - Street 1:11331 OLD HAMMOND HWY STE BC&D
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8461
Practice Address - Country:US
Practice Address - Phone:252-566-3862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
LA66021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty