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General NPI Number Information
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NPI Number | 1598209207
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Entity Type | Organization
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Legal Business Name | LAKE AREA DENTISTRY-DEQUINCY, LLC
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Dates
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Enumeration Date | 12/14/2016
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Last Update Date | 12/14/2016
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Provider Practice Location Address
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Address Line | 824 W 4TH ST
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City | DEQUINCY
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State | LA
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Zip | 70633
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Country | US
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Telephone | 337-786-6221
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Fax |
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Provider Business Mailing Address
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Address Line | 824 W 4TH ST
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City | DEQUINCY
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State | LA
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Zip | 70633
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Country | US
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Telephone | 337-786-6221
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. JEFFERY ALLEN HENNIGAN
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Credential | DDS
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Telephone | 337-786-6221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | LA-6269
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License Number State | LA
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