1679059539 NPI number — MICHAEL E WOOLBERT DDS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679059539 NPI number — MICHAEL E WOOLBERT DDS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL E WOOLBERT DDS LLC
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:
1679059539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7600 FERN AVENUE
Provider Second Line Business Mailing Address:
BUILDING 1100
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-868-8276
Provider Business Mailing Address Fax Number:
318-868-8212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7600 FERN AVENUE
Provider Second Line Business Practice Location Address:
BUILDING 1100
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-868-8276
Provider Business Practice Location Address Fax Number:
318-868-8212
Provider Enumeration Date:
07/13/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WOOLBERT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
318-868-8276

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  4020 , 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)





Copyright © 2007-2025 www.npivalidator.com