Healthcare Provider Details

I. General information

NPI: 1285875344
Provider Name (Legal Business Name): KENNETH R DUBOIS III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 N BROAD ST.
NEW ORLEANS LA
70119
US

IV. Provider business mailing address

1204 N BROAD ST.
NEW ORLEANS LA
70119
US

V. Phone/Fax

Practice location:
  • Phone: 504-821-2545
  • Fax: 504-304-1446
Mailing address:
  • Phone: 504-821-2545
  • Fax: 504-304-1446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5997
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: