Provider Demographics
NPI:1851417844
Name:LATIOLAIS, STEVEN RAYMOND (DDS)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:RAYMOND
Last Name:LATIOLAIS
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 1:1477 CRAWFORD DR
Mailing Address - Street 2:P.O. BOX 12042
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-4709
Mailing Address - Country:US
Mailing Address - Phone:337-855-2742
Mailing Address - Fax:
Practice Address - Street 1:644 HIGHWAY 171 N
Practice Address - Street 2:SUITE D
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611
Practice Address - Country:US
Practice Address - Phone:337-855-2742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 32991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1832995Medicaid