Organization
PEACH TREE FOR KIDS - RUSTON, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JESSE HENTON ROBERTS III D.D.S. (OWNER/DENTIST)
(318) 255-7760
Entity
Organization
Contact information
Practice address
206 E VAUGHN AVE, RUSTON, LA 71270-5926
(318) 255-7760
Mailing address
702 N TRENTON ST, RUSTON, LA 71270-3324
(318) 255-9440
(318) 251-1270
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
5205
LA
Other
Enumeration date
02/08/2013
Last updated
02/08/2013
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