Healthcare Provider Details

I. General information

NPI: 1083607261
Provider Name (Legal Business Name): TONY LEON GUILBEAU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 GENERAL MOUTON AVE
LAFAYETTE LA
70501-8512
US

IV. Provider business mailing address

906 GENERAL MOUTON AVE
LAFAYETTE LA
70501-8512
US

V. Phone/Fax

Practice location:
  • Phone: 337-234-4004
  • Fax: 337-234-4004
Mailing address:
  • Phone: 337-234-4004
  • Fax: 337-234-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4426
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: