Provider Demographics
NPI:1063792752
Name:IVY DENTAL
Entity type:Organization
Organization Name:IVY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRETTA
Authorized Official - Middle Name:RRENEE
Authorized Official - Last Name:PORTER-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-868-4188
Mailing Address - Street 1:460 ASHLEY RIDGE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7238
Mailing Address - Country:US
Mailing Address - Phone:318-868-4188
Mailing Address - Fax:318-868-9151
Practice Address - Street 1:460 ASHLEY RIDGE BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7238
Practice Address - Country:US
Practice Address - Phone:318-868-4188
Practice Address - Fax:318-868-9151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA46451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty