Healthcare Provider Details

I. General information

NPI: 1386182418
Provider Name (Legal Business Name): ANITA J GOURI DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 CAMELLIA BLVD.
LAFAYETTE LA
70508
US

IV. Provider business mailing address

1512 CAMELLIA BLVD
LAFAYETTE LA
70508
US

V. Phone/Fax

Practice location:
  • Phone: 337-443-9944
  • Fax: 337-981-7505
Mailing address:
  • Phone: 337-443-9944
  • Fax: 337-981-7505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5755
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANITA J GOURI
Title or Position: PRESIDENT
Credential: DDS
Phone: 337-443-9944