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General NPI Number Information
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NPI Number | 1114308582
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Entity Type | Organization
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Legal Business Name | FERN AVENUE DENTAL CENTER
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Dates
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Enumeration Date | 06/11/2015
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Last Update Date | 06/11/2015
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Provider Practice Location Address
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Address Line | 7600 FERN AVE BLDG 1100
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City | SHREVEPORT
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State | LA
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Zip | 71105-5659
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Country | US
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Telephone | 318-797-1550
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Fax |
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Provider Business Mailing Address
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Address Line | 7600 FERN AVE BLDG 1100
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City | SHREVEPORT
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State | LA
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Zip | 71105-5659
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Country | US
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Telephone | 318-797-1550
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | PAUL C HEILMAN
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Credential |
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Telephone | 318-797-1550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3291
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License Number State | LA
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