MEDICARE: LAGNIAPPE DENTAL NORTH LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1093276826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAGNIAPPE DENTAL NORTH LLC

Provider Business Mailing Address
First Line	:	4438 VIKING DR STE 100
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-7510
Country	:	US
Telephone Number	:	318-747-2666
Fax Number	:	318-747-6610

Provider Business Practice Location Address
First Line	:	1104 DOCTORS DR
Second Line	:
City	:	SPRINGHILL
State	:	LA
Zip	:	71075-4528
Country	:	US
Telephone Number	:	318-539-5642
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. ELIZABETH LANDRY MATHEWS
Credential	:	DDS
Telephone Number	:	318-747-2666

Provider Enumeration Date	:	03/26/2019
Last Update Date	:	03/26/2019

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