Provider Demographics
NPI:1063545614
Name:ELLENDER, JUDITH DIANE (DDS)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:DIANE
Last Name:ELLENDER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JUDITH
Other - Middle Name:KIKER
Other - Last Name:ELLENDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:910 1ST AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-3425
Mailing Address - Country:US
Mailing Address - Phone:337-527-6751
Mailing Address - Fax:337-527-6751
Practice Address - Street 1:910 1ST AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-3425
Practice Address - Country:US
Practice Address - Phone:337-527-6751
Practice Address - Fax:337-527-6751
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA26401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1826405Medicaid