Provider Demographics
NPI:1194721266
Name:MCVEA, CONRAD PETTIT III (DDS)
Entity type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:PETTIT
Last Name:MCVEA
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 NEEDLE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-2500
Mailing Address - Country:US
Mailing Address - Phone:985-839-5500
Mailing Address - Fax:
Practice Address - Street 1:2016 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438-2533
Practice Address - Country:US
Practice Address - Phone:985-839-4138
Practice Address - Fax:985-839-6253
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA42941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1842940Medicaid