Provider Demographics
NPI:1699873133
Name:LASALLE, MARIJA GUIDRY (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIJA
Middle Name:GUIDRY
Last Name:LASALLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 W CAUSEWAY APPROACH
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3033
Mailing Address - Country:US
Mailing Address - Phone:985-727-1133
Mailing Address - Fax:985-727-9944
Practice Address - Street 1:1580 W CAUSEWAY APPROACH
Practice Address - Street 2:SUITE 5
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3033
Practice Address - Country:US
Practice Address - Phone:985-727-1133
Practice Address - Fax:985-727-9944
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA44851223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics