MEDICARE: DR. JOHN EDWARD 'JET' TRAHAN II D.D.S., M.S.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	5907	LA

General Provider Information

NPI Number	:	1629386032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN EDWARD 'JET' TRAHAN II D.D.S., M.S.D.

Provider Business Mailing Address
First Line	:	139 GLORIA DR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-5043
Country	:	US
Telephone Number	:	337-405-0371
Fax Number	:	337-905-8998

Provider Business Practice Location Address
First Line	:	139 GLORIA DR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-5043
Country	:	US
Telephone Number	:	337-405-0371
Fax Number	:	337-905-8998

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	12/07/2023

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