Provider Demographics
NPI:1487740627
Name:FOSTER, GERALD WILEY (DDS)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:WILEY
Last Name:FOSTER
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 1:111 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5331
Mailing Address - Country:US
Mailing Address - Phone:318-387-6406
Mailing Address - Fax:318-387-7622
Practice Address - Street 1:111 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5331
Practice Address - Country:US
Practice Address - Phone:318-387-6406
Practice Address - Fax:318-387-7622
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA34011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA834017Medicaid