MEDICARE: MCVEA DENTAL CENTER

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	261QD0000X	Dental Clinic/Center	4294	LA

General Provider Information

NPI Number	:	1639529621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCVEA DENTAL CENTER

Provider Business Mailing 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

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	:	MANAGER
Name	:	DR. CONRAD PETTIT MCVEA III
Credential	:	DDS
Telephone Number	:	985-839-4138

Provider Enumeration Date	:	06/21/2016
Last Update Date	:	05/08/2017

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Directions to “MCVEA DENTAL CENTER ” Practice Location

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