Provider Demographics
NPI:1699793737
Name:LOUD, CEDRIC VARDIS (DDS)
Entity type:Individual
Prefix:DR
First Name:CEDRIC
Middle Name:VARDIS
Last Name:LOUD
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 1:1397 E GLACIER PL
Mailing Address - Street 2:DEPARTMENT OF ORAL SURGERY
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-5458
Mailing Address - Country:US
Mailing Address - Phone:480-459-7282
Mailing Address - Fax:318-631-3464
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF ORAL SURGERY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-7737
Practice Address - Fax:318-675-5666
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5366122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1853666Medicaid
V04646Medicare UPIN
LA1853666Medicaid