Healthcare Provider Details

I. General information

NPI: 1730307745
Provider Name (Legal Business Name): TED METHVIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 SOUTH DR STE 102
NATCHITOCHES LA
71457-5067
US

IV. Provider business mailing address

116 SOUTH DR STE 102
NATCHITOCHES LA
71457-5067
US

V. Phone/Fax

Practice location:
  • Phone: 318-238-3335
  • Fax: 318-238-3339
Mailing address:
  • Phone: 318-238-3335
  • Fax: 318-238-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5942
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19343
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: