Provider Demographics
NPI:1912225780
Name:FONTENOT, IAN (DDS)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:
Last Name:FONTENOT
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 1:200 HECTOR CONNOLY RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-6348
Mailing Address - Country:US
Mailing Address - Phone:337-565-2580
Mailing Address - Fax:337-565-2799
Practice Address - Street 1:200 HECTOR CONNOLY RD STE 102
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-6348
Practice Address - Country:US
Practice Address - Phone:337-565-2580
Practice Address - Fax:337-565-2799
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA59881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice