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General NPI Number Information
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NPI Number | 1679026264
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Entity Type | Organization
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Legal Business Name | KOOL SMILES
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Dates
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Enumeration Date | 07/29/2016
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Last Update Date | 07/29/2016
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Provider Practice Location Address
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Address Line | 3719 JEWELLA AVE
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City | SHREVEPORT
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State | LA
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Zip | 71109-4703
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Country | US
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Telephone | 318-759-0905
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Fax |
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Provider Business Mailing Address
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Address Line | 3719 JEWELLA AVE,
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City | SHREVEPORT
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State | LA
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Zip | 71109
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Country | US
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Telephone | 318-573-9918
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Fax |
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | MR. JESSIE DIXON
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Credential | DDS
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Telephone | 678-285-4807
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6698
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License Number State | LA
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