Basic Information
| Provider Information | |||||||||
| NPI: | 1528241064 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDS DENTAL ZONE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 E GAUSE BLVD | ||||||||
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| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856413988 | ||||||||
| FaxNumber: | 9856462536 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 LAPALCO BLVD | ||||||||
| Address2: | SUITE 16 17 18 19 | ||||||||
| City: | HARVEY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043402004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2007 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | DONALDSON | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9856413988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.