NPIMap

Organization Active NPI

Fern Avenue Dentistry, LLC

  • General Practice Dentistry
  • Shreveport, LA
National Provider Identifier
1447469069
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
5313 Issued in LA
Legal business name
FERN AVENUE DENTISTRY, LLC
Practice address
8535 Fern Ave # 2
Shreveport, LA 71105-5656
Phone
(318) 798-3376
Fax
(318) 798-3310
NPI assigned
May 21, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Brian Kennedy Broadwell, DDS
Title
Dentist, Owner
Phone
(318) 798-3376

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X 5313 LA Primary

Addresses

Primary practice location

8535 Fern Ave # 2
Shreveport, LA 71105-5656

Mailing address

8535 Fern Ave # 2
Shreveport, LA 71105-5656
Phone (318) 798-3376

National Provider Directory

National Provider Directory

Locations

8535 Fern Ave
#2
Shreveport, LA 71105
Phone (318) 798-3376

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179705600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1447469069",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8535 FERN AVE # 2",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711055656",
            "telephone_number": "318-798-3376",
            "fax_number": "318-798-3310"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8535 FERN AVE # 2",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711055656",
            "telephone_number": "318-798-3376",
            "fax_number": "318-798-3310"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FERN AVENUE DENTISTRY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-21",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BROADWELL",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "KENNEDY",
        "authorized_official_title_or_position": "DENTIST, OWNER",
        "authorized_official_telephone_number": "318-798-3376",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "LA",
            "license": "5313",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Shreveport, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.