MEDICARE: SR BOSSIER 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1821722240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SR BOSSIER LLC

Provider Business Mailing Address
First Line	:	2369 AIRLINE DR STE 330
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-5867
Country	:	US
Telephone Number	:	318-658-9622
Fax Number	:	318-658-9628

Provider Business Practice Location Address
First Line	:	2369 AIRLINE DR STE 330
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-5867
Country	:	US
Telephone Number	:	318-658-9622
Fax Number	:	318-658-9628

Authorized Official
Title or Position	:	PRACTICE MANAGEMENT
Name	:	ABIGAIL RENEE HOWELL
Credential	:
Telephone Number	:	318-294-2241

Provider Enumeration Date	:	07/12/2022
Last Update Date	:	07/12/2022

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