Provider Demographics
NPI:1538213004
Name:LARSON, JILL LEBLANC (DDS)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:LEBLANC
Last Name:LARSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:LEBLANC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:601EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:VILLE PLATTE
Mailing Address - State:LA
Mailing Address - Zip Code:70586
Mailing Address - Country:US
Mailing Address - Phone:337-363-7766
Mailing Address - Fax:337-363-1092
Practice Address - Street 1:601EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:VILLE PLATTE
Practice Address - State:LA
Practice Address - Zip Code:70586
Practice Address - Country:US
Practice Address - Phone:337-363-7766
Practice Address - Fax:337-363-1092
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4736122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1847364Medicaid