Provider Demographics
NPI:1154877686
Name:EDWARD C MASSETT JR. DDS APC
Entity type:Organization
Organization Name:EDWARD C MASSETT JR. DDS APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:985-641-2030
Mailing Address - Street 1:2334 GAUSE BLVD. EAST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461
Mailing Address - Country:US
Mailing Address - Phone:985-641-2030
Mailing Address - Fax:985-645-0272
Practice Address - Street 1:2334 GAUSE BLVD E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4141
Practice Address - Country:US
Practice Address - Phone:985-641-2030
Practice Address - Fax:985-645-0272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23681223S0112X
LA1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1823686Medicaid
LA1857149Medicaid