Provider Demographics
NPI:1861576324
Name:CHURCHMAN, CARL WILLIAM JR (DDS)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:WILLIAM
Last Name:CHURCHMAN
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 1:3425 LOUISIANA AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-1851
Mailing Address - Country:US
Mailing Address - Phone:337-477-5043
Mailing Address - Fax:337-477-5085
Practice Address - Street 1:3425 LOUISIANA AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-1851
Practice Address - Country:US
Practice Address - Phone:337-477-5043
Practice Address - Fax:337-477-5085
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855570Medicaid