Healthcare Provider Details

I. General information

NPI: 1720803356
Provider Name (Legal Business Name): SHREVEPORT PERIODONTAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 EDGEMONT ST
SHREVEPORT LA
71106-2246
US

IV. Provider business mailing address

745 EDGEMONT ST
SHREVEPORT LA
71106-2246
US

V. Phone/Fax

Practice location:
  • Phone: 318-868-0535
  • Fax: 318-868-0572
Mailing address:
  • Phone: 318-868-0535
  • Fax: 318-868-0572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: ANGELA WATSON
Title or Position: COO
Credential:
Phone: 318-868-0535