Provider Demographics
NPI:1548497738
Name:MEREDITH, MARK M JR (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:MEREDITH
Suffix:JR
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:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-0360
Mailing Address - Country:US
Mailing Address - Phone:318-649-6161
Mailing Address - Fax:318-649-6161
Practice Address - Street 1:8066 HWY 165
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418
Practice Address - Country:US
Practice Address - Phone:318-649-6161
Practice Address - Fax:318-649-6161
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1859753Medicaid