Healthcare Provider Details

I. General information

NPI: 1720717275
Provider Name (Legal Business Name): CHRISTINE LE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 AIRLINE DR
BOSSIER CITY LA
71111
US

IV. Provider business mailing address

4325 AIRLINE DR
BOSSIER CITY LA
71111-2003
US

V. Phone/Fax

Practice location:
  • Phone: 318-742-9333
  • Fax:
Mailing address:
  • Phone: 832-420-0610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number39273
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7579
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: