=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295380418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W. J. DUDLEY DENTURE CONSULTANTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2019
-----------------------------------------------------
Last Update Date | 08/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4354 PINES RD
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71119-7738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-635-1970
-----------------------------------------------------
Fax | 318-635-1972
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4354 PINES RD
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71119-7738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-635-1970
-----------------------------------------------------
Fax | 318-635-1972
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOOKKEPER
-----------------------------------------------------
Name | MRS. ERINN PUMPHREY DUDLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-422-0397
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------