MEDICARE: DR. CONRAD PETTIT MCVEA III DDS

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	4294	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194721266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONRAD PETTIT MCVEA III DDS

Provider Business Mailing Address
First Line	:	1022 NEEDLE RD
Second Line	:
City	:	FRANKLINTON
State	:	LA
Zip	:	70438-2500
Country	:	US
Telephone Number	:	985-839-5500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2016 WASHINGTON ST
Second Line	:
City	:	FRANKLINTON
State	:	LA
Zip	:	70438-2533
Country	:	US
Telephone Number	:	985-839-4138
Fax Number	:	985-839-6253

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	07/09/2007

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