Healthcare Provider Details

I. General information

NPI: 1083675946
Provider Name (Legal Business Name): LORIE A. MOREAU, D.D.S., A.P.D.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 SAINT CHARLES ST SUITE 1000
HOUMA LA
70360-5014
US

IV. Provider business mailing address

1463 SAINT CHARLES ST SUITE 1000
HOUMA LA
70360-5014
US

V. Phone/Fax

Practice location:
  • Phone: 985-853-0001
  • Fax: 985-853-0024
Mailing address:
  • Phone: 985-853-0001
  • Fax: 985-853-0024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5263
License Number StateLA

VIII. Authorized Official

Name: LORIE MOREAU GODAIL
Title or Position: OWNER, DENTIST
Credential: D.D.S.
Phone: 985-853-0001