Healthcare Provider Details

I. General information

NPI: 1386709285
Provider Name (Legal Business Name): EDWARD CHARLES MASSETT JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2334 GAUSE BLVD EAST
SLIDELL LA
70461
US

IV. Provider business mailing address

2334 GAUSE BLVD EAST
SLIDELL LA
70461
US

V. Phone/Fax

Practice location:
  • Phone: 985-641-2030
  • Fax: 985-645-0272
Mailing address:
  • Phone: 985-641-2030
  • Fax: 985-645-0272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number2368
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2368
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: