Basic Information
| Provider Information | |||||||||
| NPI: | 1003141342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | SHADONNA | ||||||||
| MiddleName: | DANIELLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.D.S. | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 6012 | LA | Y | Dental Providers | Dentist | General Practice |
No ID Information.