Provider Demographics
NPI:1396272480
Name:BERTHELOT, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:BERTHELOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 CHATEAU LOIRE CIR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-7055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:842 COLLINS BLVD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2759
Practice Address - Country:US
Practice Address - Phone:985-809-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA67411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice