Healthcare Provider Details

I. General information

NPI: 1730549700
Provider Name (Legal Business Name): DLS OF ALEXANDRIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 MASONIC DR
ALEXANDRIA LA
71301-3628
US

IV. Provider business mailing address

3820 MASONIC DR
ALEXANDRIA LA
71301-3628
US

V. Phone/Fax

Practice location:
  • Phone: 318-442-9555
  • Fax: 318-442-0475
Mailing address:
  • Phone: 318-442-9555
  • Fax: 318-442-0475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3992
License Number StateLA

VIII. Authorized Official

Name: JOHN C MOREAU JR.
Title or Position: OWNER
Credential: DDS
Phone: 318-442-9555