1952760100 NPI number — DR. ROBERT J. SPEARS FAMILY DENTISTRY

Table of content: DR. SEAN MATTHEW WETJEN MD (NPI 1285298257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952760100 NPI number — DR. ROBERT J. SPEARS FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. ROBERT J. SPEARS FAMILY DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952760100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9235 LAKE FOREST BLVD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70127-3043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-241-8214
Provider Business Mailing Address Fax Number:
504-241-2246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9235 LAKE FOREST BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70127-3043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-241-8214
Provider Business Practice Location Address Fax Number:
504-241-2246
Provider Enumeration Date:
02/16/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SPEARS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
504-241-8214

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1835994 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2378414 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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