Basic Information
| Provider Information | |||||||||
| NPI: | 1700020708 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OCEAN DENTAL OF LOUISIANA, P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 206 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057070600 | ||||||||
| FaxNumber: | 4057070601 | ||||||||
| Practice Location | |||||||||
| Address1: | 1297 SHREVEPORT BARKSDALE HWY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711052405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057070600 | ||||||||
| FaxNumber: | 4057070601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2009 | ||||||||
| LastUpdateDate: | 04/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | HOECKER | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | BRANDON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4057070600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.D.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.