Healthcare Provider Details

I. General information

NPI: 1285776872
Provider Name (Legal Business Name): BUNKIE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 NW MAIN ST
BUNKIE LA
71322
US

IV. Provider business mailing address

1002 NW MAIN ST
BUNKIE LA
71322
US

V. Phone/Fax

Practice location:
  • Phone: 318-346-9585
  • Fax: 318-346-9596
Mailing address:
  • Phone: 318-346-9585
  • Fax: 318-346-9596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. SEAN ASHLEY JOHNSON
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 318-346-9585