Healthcare Provider Details

I. General information

NPI: 1487294724
Provider Name (Legal Business Name): SOUTH LOUISIANA DENTOFACIAL SENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 VALHI BLVD
HOURNA LA
70360
US

IV. Provider business mailing address

600 VALHI BLVD
HOURNA LA
70360
US

V. Phone/Fax

Practice location:
  • Phone: 985-872-3677
  • Fax: 985-872-3680
Mailing address:
  • Phone: 985-872-3677
  • Fax: 985-872-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. PEDRO J. CUARTAS
Title or Position: DENTIST
Credential: DDS
Phone: 985-872-3677