Healthcare Provider Details

I. General information

NPI: 1396848834
Provider Name (Legal Business Name): EDDY WALLER SHERMAN II DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9915 HWY 79
HAYNESVILLE LA
71038
US

IV. Provider business mailing address

PO BOX 188 9915 HWY 79
HAYNESVILLE LA
71038
US

V. Phone/Fax

Practice location:
  • Phone: 318-624-1880
  • Fax: 318-624-1001
Mailing address:
  • Phone: 318-624-1880
  • Fax: 318-624-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5738
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: