Provider Demographics
NPI:1730549700
Name:DLS OF ALEXANDRIA
Entity type:Organization
Organization Name:DLS OF ALEXANDRIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOREAU
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-442-9555
Mailing Address - Street 1:3820 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3628
Mailing Address - Country:US
Mailing Address - Phone:318-442-9555
Mailing Address - Fax:318-442-0475
Practice Address - Street 1:3820 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3628
Practice Address - Country:US
Practice Address - Phone:318-442-9555
Practice Address - Fax:318-442-0475
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DLS OF ALEXANDRIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA39921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1839922Medicaid