Basic Information
| Provider Information | |||||||||
| NPI: | 1023138849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 W PRIEN LAKE RD | ||||||||
| Address2: | SUITE B223 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706010700 | ||||||||
| 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: | 03/29/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2380 | LA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1823805 | 05 | LA | MEDICAID |