Provider Demographics
NPI:1386709285
Name:MASSETT, EDWARD CHARLES JR (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:CHARLES
Last Name:MASSETT
Suffix:JR
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 1:2334 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 EAST
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461
Practice Address - Country:US
Practice Address - Phone:985-641-2030
Practice Address - Fax:985-645-0272
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23681223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1823686Medicaid
MS00450504Medicaid
LA58232Medicare ID - Type Unspecified
MS00450504Medicaid