Basic Information
| Provider Information | |||||||||
| NPI: | 1689810426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KID'S DENTAL ZONE ALEXANDRIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 GAUSE BLVD E | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704614153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856413988 | ||||||||
| FaxNumber: | 9856415182 | ||||||||
| Practice Location | |||||||||
| Address1: | 616B MACARTHUR DR | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713033111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856413988 | ||||||||
| FaxNumber: | 9856415182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2008 | ||||||||
| LastUpdateDate: | 12/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | DONALDSON | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | LAWRENCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9856413988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.