Healthcare Provider Details

I. General information

NPI: 1598209207
Provider Name (Legal Business Name): LAKE AREA DENTISTRY-DEQUINCY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 W 4TH ST
DEQUINCY LA
70633
US

IV. Provider business mailing address

824 W 4TH ST
DEQUINCY LA
70633
US

V. Phone/Fax

Practice location:
  • Phone: 337-786-6221
  • Fax:
Mailing address:
  • Phone: 337-786-6221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberLA-6269
License Number StateLA

VIII. Authorized Official

Name: DR. JEFFERY ALLEN HENNIGAN
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 337-786-6221