=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942715917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONROE DENTAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2017
-----------------------------------------------------
Last Update Date | 12/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 N 18TH ST STE E
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-4972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-605-2015
-----------------------------------------------------
Fax | 318-737-1239
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1503 SPENCER AVE
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-4149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-557-6338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. JULIE LEBELL SIMPSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 318-605-2015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------