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General NPI Number Information
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NPI Number | 1679059539
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Entity Type | Organization
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Legal Business Name | MICHAEL E WOOLBERT DDS LLC
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Dates
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Enumeration Date | 07/13/2018
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Last Update Date | 07/13/2018
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Provider Practice Location Address
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Address Line | 7600 FERN AVENUE BUILDING 1100
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City | SHREVEPORT
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State | LA
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Zip | 71105
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Country | US
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Telephone | 318-868-8276
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Fax | 318-868-8212
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Provider Business Mailing Address
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Address Line | 7600 FERN AVENUE BUILDING 1100
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City | SHREVEPORT
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State | LA
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Zip | 71105
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Country | US
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Telephone | 318-868-8276
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Fax | 318-868-8212
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Authorized Official
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Title or Position | MANAGER
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Name | MICHAEL EDWARD WOOLBERT
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Credential | DDS
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Telephone | 318-868-8276
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4020
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License Number State | LA
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