MEDICARE: LAKE AREA DENTISTRY-CARLYSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	LA-6269	LA

General Provider Information

NPI Number	:	1043706252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE AREA DENTISTRY-CARLYSS

Provider Business Mailing Address
First Line	:	4985 HIGHWAY 27 S
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70665-7571
Country	:	US
Telephone Number	:	337-583-2756
Fax Number	:

Provider Business Practice Location Address
First Line	:	4985 HIGHWAY 27 S
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70665-7571
Country	:	US
Telephone Number	:	337-583-2756
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEFFERY HENNIGAN
Credential	:	DDS
Telephone Number	:	337-478-8470

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	07/11/2018

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