=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154661064
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RED RIVER DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2013
-----------------------------------------------------
Last Update Date | 03/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1408 PETERMAN DR
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71301-3432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-427-9220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1408 PETERMAN DR
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71301-3432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-427-9220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/MANAGER
-----------------------------------------------------
Name | DR. WILLIAM ALAN PUCKETT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 318-427-9220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 5978
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------