Healthcare Provider Details

I. General information

NPI: 1487859567
Provider Name (Legal Business Name): AMELIA JOAN SLAY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1297 SHREVEPORT BARKSDALE HWY
SHREVEPORT LA
71105-2405
US

IV. Provider business mailing address

1297 SHREVEPORT BARKSDALE HWY
SHREVEPORT LA
71105-2405
US

V. Phone/Fax

Practice location:
  • Phone: 318-865-8725
  • Fax: 318-869-4725
Mailing address:
  • Phone: 318-865-8725
  • Fax: 318-869-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013569
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5940
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: