MEDICARE: KIDS DENTAL ZONE 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1528241064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS DENTAL ZONE LLC

Provider Business Mailing Address
First Line	:	2960 E GAUSE BLVD
Second Line	:
City	:	SLIDELL
State	:	LA
Zip	:	70461
Country	:	US
Telephone Number	:	985-641-3988
Fax Number	:	985-646-2536

Provider Business Practice Location Address
First Line	:	4001 LAPALCO BLVD
Second Line	:	SUITE 16 17 18 19
City	:	HARVEY
State	:	LA
Zip	:	70058
Country	:	US
Telephone Number	:	504-340-2004
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EDWARD L DONALDSON JR.
Credential	:	DDS
Telephone Number	:	985-641-3988

Provider Enumeration Date	:	12/06/2007
Last Update Date	:	12/06/2007

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