MEDICARE: SOUTHERN SMILES OF IBERIA, INC

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	5394	LA

General Provider Information

NPI Number	:	1225355076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN SMILES OF IBERIA, INC

Provider Business Mailing Address
First Line	:	715 N LEWIS ST
Second Line	:
City	:	NEW IBERIA
State	:	LA
Zip	:	70563-2045
Country	:	US
Telephone Number	:	337-234-2186
Fax Number	:	337-234-1573

Provider Business Practice Location Address
First Line	:	715 N LEWIS ST
Second Line	:
City	:	NEW IBERIA
State	:	LA
Zip	:	70563-2045
Country	:	US
Telephone Number	:	337-234-2186
Fax Number	:	337-234-1573

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. TIMOTHY L CHAUVIN
Credential	:	DDS
Telephone Number	:	337-234-2186

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	05/03/2010

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