Healthcare Provider Details

I. General information

NPI: 1093122202
Provider Name (Legal Business Name): COLTEN DUCOTE DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2014
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 FERN AVE STE 600
SHREVEPORT LA
71105-5688
US

IV. Provider business mailing address

7600 FERN AVE STE 600
SHREVEPORT LA
71105-5688
US

V. Phone/Fax

Practice location:
  • Phone: 318-797-5812
  • Fax:
Mailing address:
  • Phone: 318-797-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6495
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: