Provider Demographics
NPI:1215152392
Name:DR. DWIGHT D LANDRY A PROFESSIONAL DENTAL CORPORATION - GEISMAR
Entity type:Organization
Organization Name:DR. DWIGHT D LANDRY A PROFESSIONAL DENTAL CORPORATION - GEISMAR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:D
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-673-0000
Mailing Address - Street 1:13353 HIGHWAY 73
Mailing Address - Street 2:SUITE A
Mailing Address - City:GEISMAR
Mailing Address - State:LA
Mailing Address - Zip Code:70734-3000
Mailing Address - Country:US
Mailing Address - Phone:225-673-0000
Mailing Address - Fax:225-673-1807
Practice Address - Street 1:13353 HIGHWAY 73
Practice Address - Street 2:SUITE A
Practice Address - City:GEISMAR
Practice Address - State:LA
Practice Address - Zip Code:70734-3000
Practice Address - Country:US
Practice Address - Phone:225-673-0000
Practice Address - Fax:225-673-1807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA37081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1837083Medicaid