Healthcare Provider Details

I. General information

NPI: 1932263506
Provider Name (Legal Business Name): PERIODONTICS ASSOCIATES, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3839 W CONGRESS ST SUITE D
LAFAYETTE LA
70506-6000
US

IV. Provider business mailing address

3839 W CONGRESS ST SUITE D
LAFAYETTE LA
70506-6000
US

V. Phone/Fax

Practice location:
  • Phone: 337-989-0267
  • Fax: 337-989-9030
Mailing address:
  • Phone: 337-989-0267
  • Fax: 337-989-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3129
License Number StateLA

VIII. Authorized Official

Name: DR. MARK RANDAL COMEAUX
Title or Position: PARTNER
Credential: DDS
Phone: 337-989-0267