Healthcare Provider Details

I. General information

NPI: 1134262058
Provider Name (Legal Business Name): RODRICK ELLIS LOUD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 FREDERICK ST
SHREVEPORT LA
71109-3607
US

IV. Provider business mailing address

586 ONEONTA ST
SHREVEPORT LA
71106-1620
US

V. Phone/Fax

Practice location:
  • Phone: 318-631-3464
  • Fax:
Mailing address:
  • Phone: 318-349-0167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5534
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1255
License Number StateVI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: