Provider Demographics
NPI:1528535960
Name:LAKE AREA DENTISTRY- MOSS BLUFF
Entity type:Organization
Organization Name:LAKE AREA DENTISTRY- MOSS BLUFF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-855-2742
Mailing Address - Street 1:644 N HIGHWAY 171
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-5348
Mailing Address - Country:US
Mailing Address - Phone:337-855-2742
Mailing Address - Fax:
Practice Address - Street 1:644 N HIGHWAY 171
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5348
Practice Address - Country:US
Practice Address - Phone:337-855-2742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental