MEDICARE: DR. DWIGHT D LANDRY A PROFESSIONAL DENTAL CORPORATION - GEISMAR

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	3708	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	:	1215152392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. DWIGHT D LANDRY A PROFESSIONAL DENTAL CORPORATION - GEISMAR

Provider Business Mailing Address
First Line	:	13353 HIGHWAY 73
Second Line	:	SUITE A
City	:	GEISMAR
State	:	LA
Zip	:	70734-3000
Country	:	US
Telephone Number	:	225-673-0000
Fax Number	:	225-673-1807

Provider Business Practice Location Address
First Line	:	13353 HIGHWAY 73
Second Line	:	SUITE A
City	:	GEISMAR
State	:	LA
Zip	:	70734-3000
Country	:	US
Telephone Number	:	225-673-0000
Fax Number	:	225-673-1807

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DWIGHT D LANDRY
Credential	:	D.D.S
Telephone Number	:	225-673-0000

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	09/03/2009

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