=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003943135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC DENTIST, PDC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 VETERANS MEMORIAL BLVD SUITE 306
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-831-2120
-----------------------------------------------------
Fax | 504-831-2310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2201 VETERANS MEMORIAL BLVD SUITE 306
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-831-2120
-----------------------------------------------------
Fax | 504-831-2310
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JASON D PARKER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 504-669-8679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 5132
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------