Basic Information
Provider Information | |||||||||
NPI: | 1053383158 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JEFFREY W. DONGIEUX, D.D.S. A PROFESSIONAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 W ESPLANADE AVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | KENNER | ||||||||
State: | LA | ||||||||
PostalCode: | 700653463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5044688300 | ||||||||
FaxNumber: | 5044688307 | ||||||||
Practice Location | |||||||||
Address1: | 1900 W ESPLANADE AVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | KENNER | ||||||||
State: | LA | ||||||||
PostalCode: | 700653463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5044688300 | ||||||||
FaxNumber: | 5044688307 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5044688300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 5529 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
ID | Type | State | Issuer | Description | 1855294 | 05 | LA |   | MEDICAID |