Healthcare Provider Details

I. General information

NPI: 1609303700
Provider Name (Legal Business Name): EDWIN FREDRICK TRAUTH IV DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 05/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40470 GERMANY RD
GONZALES LA
70737-6735
US

IV. Provider business mailing address

122 SAM ST
BOUTTE LA
70039-3528
US

V. Phone/Fax

Practice location:
  • Phone: 225-622-2022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6754
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: