Healthcare Provider Details

I. General information

NPI: 1366822710
Provider Name (Legal Business Name): A BRIGHTER SMILE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 BERT KOUNS LOOP SUITE 700
SHREVEPORT LA
71106-8158
US

IV. Provider business mailing address

385 BERT KOUNS LOOP SUITE 700
SHREVEPORT LA
71106-8158
US

V. Phone/Fax

Practice location:
  • Phone: 318-688-9330
  • Fax: 318-688-1183
Mailing address:
  • Phone: 318-688-9330
  • Fax: 318-688-1183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5831
License Number StateLA

VIII. Authorized Official

Name: INGER WHITTINGTON
Title or Position: INSURANCE CLERK
Credential:
Phone: 318-688-9330