=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366590713
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLAYTON J CHARBONNET JR. D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5036 YALE ST STE 301
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70006-3980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-456-7874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1905 W THOMAS ST STE M
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70401-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-340-3838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 2349
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------