Provider Demographics
NPI:1023138849
Name:SHORT, RONALD MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:MICHAEL
Last Name:SHORT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W PRIEN LAKE RD
Mailing Address - Street 2:SUITE B223
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-0700
Mailing Address - Country:US
Mailing Address - Phone:337-310-1800
Mailing Address - Fax:337-310-1143
Practice Address - Street 1:1702 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8912
Practice Address - Country:US
Practice Address - Phone:337-310-1800
Practice Address - Fax:337-310-1143
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1823805Medicaid