=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467665505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEVEREUX AND NGUYEN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 05/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 MANHATTAN BLVD. SUITE D
-----------------------------------------------------
City | HARVEY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70058-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-368-7513
-----------------------------------------------------
Fax | 504-368-3932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2800 MANHATTAN BLVD. SUITE D
-----------------------------------------------------
City | HARVEY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70058-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-368-7513
-----------------------------------------------------
Fax | 504-368-3932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND ORTHODONTIST
-----------------------------------------------------
Name | DR. JACK P DEVEREUX
-----------------------------------------------------
Credential | D.D.S., M.S.
-----------------------------------------------------
Telephone | 504-368-7513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 5714
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 3676
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------