Healthcare Provider Details

I. General information

NPI: 1174275515
Provider Name (Legal Business Name): WEST LOUISIANA DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 BELVIEW RD
LEESVILLE LA
71446-2902
US

IV. Provider business mailing address

103 BELVIEW RD
LEESVILLE LA
71446-2902
US

V. Phone/Fax

Practice location:
  • Phone: 337-239-2509
  • Fax: 337-239-9764
Mailing address:
  • Phone: 337-239-2509
  • Fax: 337-239-9764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. TAMMY L ARTHUR
Title or Position: BUSINESS MANAGER
Credential:
Phone: 337-239-2509