Healthcare Provider Details

I. General information

NPI: 1538092978
Provider Name (Legal Business Name): CAILYN GRACE BOBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 C M FAGAN DR STE A
HAMMOND LA
70403-6055
US

IV. Provider business mailing address

337 LONG LAKE DR
COVINGTON LA
70435-0293
US

V. Phone/Fax

Practice location:
  • Phone: 985-792-7046
  • Fax:
Mailing address:
  • Phone: 985-705-7474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7821
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: