Provider Demographics
NPI:1932227113
Name:PHILLIP L STELLY DDS
Entity Type:Organization
Organization Name:PHILLIP L STELLY DDS
Other - Org Name:PHILLIP L STELLY DDS A PROFESSIONEL DENTAL CORP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:STELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-896-3267
Mailing Address - Street 1:258 ARCENEAUX RD
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520
Mailing Address - Country:US
Mailing Address - Phone:337-896-3267
Mailing Address - Fax:337-896-7852
Practice Address - Street 1:258 ARCENEAUX RD
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520
Practice Address - Country:US
Practice Address - Phone:337-896-9132
Practice Address - Fax:337-896-7852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4453122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1844535Medicaid