Provider Demographics
NPI:1720341910
Name:LOUISIANA DENTAL PROFESSIONALS, DR. JAMINI MWENDO, D.D.S., A PROFESSIO
Entity Type:Organization
Organization Name:LOUISIANA DENTAL PROFESSIONALS, DR. JAMINI MWENDO, D.D.S., A PROFESSIO
Other - Org Name:BLUEBONNET DENTAL CARE- GRETNA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUP
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:400 LAPALCO BOULEVARD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056
Mailing Address - Country:US
Mailing Address - Phone:504-392-4384
Mailing Address - Fax:504-433-9401
Practice Address - Street 1:400 LAPALCO BOULEVARD
Practice Address - Street 2:SUITE B
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056
Practice Address - Country:US
Practice Address - Phone:504-392-4384
Practice Address - Fax:504-433-9401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUISIANA DENTAL PROFESSIONALS, DR JIMANI.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-21
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty