Provider Demographics
NPI:1720803356
Name:SHREVEPORT PERIODONTAL SPECIALISTS
Entity type:Organization
Organization Name:SHREVEPORT PERIODONTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-868-0535
Mailing Address - Street 1:745 EDGEMONT ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-2246
Mailing Address - Country:US
Mailing Address - Phone:318-868-0535
Mailing Address - Fax:318-868-0572
Practice Address - Street 1:745 EDGEMONT ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2246
Practice Address - Country:US
Practice Address - Phone:318-868-0535
Practice Address - Fax:318-868-0572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty