Healthcare Provider Details

I. General information

NPI: 1124443064
Provider Name (Legal Business Name): RACHEL A BISHOP D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2014
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5718 MARINA BAY DR
SHREVEPORT LA
71119-3918
US

IV. Provider business mailing address

5718 MARINA BAY DR
SHREVEPORT LA
71119-3918
US

V. Phone/Fax

Practice location:
  • Phone: 903-387-0728
  • Fax:
Mailing address:
  • Phone: 903-387-0728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number322567
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS5561
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: