Basic Information
Provider Information
NPI: 1003141342
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COLEMAN
FirstName: SHADONNA
MiddleName: DANIELLE
NamePrefix:  
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1702 OAK PARK BLVD
Address2:  
City: LAKE CHARLES
State: LA
PostalCode: 706018912
CountryCode: US
TelephoneNumber: 3373101800
FaxNumber: 3373101143
Practice Location
Address1: 1702 OAK PARK BLVD
Address2:  
City: LAKE CHARLES
State: LA
PostalCode: 706018912
CountryCode: US
TelephoneNumber: 3373101800
FaxNumber: 3373101143
Other Information
ProviderEnumerationDate: 10/05/2009
LastUpdateDate: 10/05/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X6012LAY Dental ProvidersDentistGeneral Practice

No ID Information.


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