Provider Demographics
NPI:1396702908
Name:WOOLBERT, MICHAEL EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:WOOLBERT
Suffix:
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 1:3100 WOODLAWN AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-4637
Mailing Address - Country:US
Mailing Address - Phone:318-868-8276
Mailing Address - Fax:318-868-8212
Practice Address - Street 1:3100 WOODLAWN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4637
Practice Address - Country:US
Practice Address - Phone:318-868-8276
Practice Address - Fax:318-868-8212
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1840203Medicaid