Provider Demographics
NPI:1285875344
Name:DUBOIS, KENNETH R III (DDS)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
Last Name:DUBOIS
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 1:1204 N BROAD ST.
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119
Mailing Address - Country:US
Mailing Address - Phone:504-821-2545
Mailing Address - Fax:504-304-1446
Practice Address - Street 1:1204 N BROAD ST.
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119
Practice Address - Country:US
Practice Address - Phone:504-821-2545
Practice Address - Fax:504-304-1446
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-18
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA59971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1859974Medicaid