Healthcare Provider Details

I. General information

NPI: 1124459110
Provider Name (Legal Business Name): ALAN C PERRY DDS (A PROFESSIONAL DENTAL CORPORATION)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1837 W PRIEN LAKE RD
LAKE CHARLES LA
70605-1223
US

IV. Provider business mailing address

1837 WEST PRIEN LAKE ROAD
LAKE CHARLES LA
70605
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-4608
  • Fax:
Mailing address:
  • Phone: 337-478-4608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3016
License Number StateLA

VIII. Authorized Official

Name: ALAN CARL PERRY
Title or Position: ORTHODONTIST
Credential: D.D.S.
Phone: 337-478-4608