MEDICARE: MARION JACK STIGALL D.D.S.

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	2333	LA

General Provider Information

NPI Number	:	1093735169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARION JACK STIGALL D.D.S.

Provider Business Mailing Address
First Line	:	2495 SHREVEPORT HIGHWAY
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71306-0000
Country	:	US
Telephone Number	:	318-473-0010
Fax Number	:	318-483-5168

Provider Business Practice Location Address
First Line	:	2495 SHREVEPORT HIGHWAY
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71306-0000
Country	:	US
Telephone Number	:	318-473-0010
Fax Number	:	318-483-5168

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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