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Attachment F.1.A Proposed Provider Network ListingLast NameThompsonTouchetFirst Name TitleJamesToddDDSDDSPractice Name/Provider NameDuos & ThompsonTouchet Family Dentistry, LLCBusiness Address204 S. 5th Street117 Blue Lake DriveCityIotaCrowleySTZipProvider TypeLALA70543 General Dentist70526 General DentistMedicaidSpecialty CodeAcceptiong NewPatients Y/N6666yyAge RestrictionNo restrictions 21, Adults - dentures onlyPCD - PotentialLinkages97629762LOI or ContractSTP Y/NParishLOILOIYNAcadiaAcadiaMarch 2013
Attachment F.1.A Proposed Provider Network ListingLast NameFirst Name TitlePractice Name/Provider NameBusiness AddressCitySTZipProvider TypeMedicaidSpecialty CodeAcceptiong NewPatients Y/NAge RestrictionPCD - PotentialLinkagesLOI or ContractSTP Y/NParishMarch 2013
Attachment F.1.A Proposed Provider Network ListingLast Name First Name DDSDDSPractice Name/Provider NameAscension Dental Associates LLCLisa C. Bailey, DDSCapitol City Family Health CenterCapitol City Family Health CenterRandall A. Bergeron, DDSAssociates in Pediatric DentistAssociates in Pediatric DentistOutreach DentistryAssociates in Pediatric DentistAssociates in Pediatric DentistOutreach DentistryAscension Dental Associates LLCAccension EndodontistCapitol City Family Health CenterCapitol City Family Health CenterAscension Dental Associates LLCAscension Dental Associates LLCAscension Dental Associates LLCDutchtown Dental CenterA Professional Dental CorporationAssociates in Pediatric DentistAssociates in Pediatric DentistAscension Dental Associates LLCAscension Dental Associates LLCAscension Dental Associates LLCCapitol City Family Health CenterCapitol City Family Health CenterAssociates in Pediatric DentistAssociates in Pediatric DentistCapitol City Family Health CenterCapitol City Family Health CenterAscension Dental Associates LLCBusiness Address40470 Germany Road225 West Ascension St38210 Highway 3089904 Catalpa Street1516 East Hwy 3013375 LA Hwy 73, Ste B17534 Old Jefferson Hwy, Ste C137093 Timothy Drive13375 LA Hwy 73, Ste B17534 Old Jefferson Hwy, Ste C139351 Seaside Lane40470 Germany Road17563 Old Jefferson Hwy38210 Highway 3089904 Catalpa Street40470 Germany Road40470 Germany Road40470 Germany Road13353 Hwy 73, Ste A1516 East Hwy 3013375 LA Hwy 73, Ste B17534 Old Jefferson Hwy, Ste C140470 Germany Road40470 Germany Road40470 Germany Road38210 Highway 3089904 Catalpa Street13375 LA Hwy 73, Ste B17534 Old Jefferson Hwy, Ste C138210 Highway 3089904 Catalpa Street40470 Germany LALALALALALALALAProvider TypeGeneral DentistGeneral DentistGeneral DentistGeneral DentistPediatric DentistPediatric DentistPediatric DentistGeneral DentistPediatric DentistPediatric DentistGeneral DentistOrthodontistEndodontistGeneral DentistGeneral DentistGeneral DentistOrthodontistGeneral DentistGeneral DentistPediatric DentistPediatric DentistPediatric DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistPediatric DentistPediatric DentistGeneral DentistGeneral DentistGeneral DentistAcceptiongMedicaidNew PatientsSpecialty yyyAge RestrictionnNo restrictionsNo restrictionsNo restrictionsNo restrictions1-19,Physically Handicapped 18 18No restrictions 18 18No restrictionsNo restrictions0-21No restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictions0-18 18 18No restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictions 18 18No restrictionsNo restrictionsNo restrictionsPCD - Potential LOI orSTP nAscensionAscensionAscensionMarch 2013
Attachment F.1.A Proposed Provider Network ListingLast NameFirst Name TitlePractice Name/Provider NameBusiness AddressCitySTZipProvider TypeMedicaidSpecialty CodeAcceptiong NewPatients Y/NAge RestrictionPCD - PotentialLinkagesLOI or ContractSTP Y/NParishMarch 2013
Attachment F.1.A Proposed Provider Network ListingLast Name First Name hnDDSDDSDDSDDSPractice Name/Provider NameRene Desselle, DDSBunkie DentistryMcCann Family DentistryJohn H Mitchell Jr DDSBusiness Address1837 L'Eglise Street1002 NW Main St135 La Rue De Medicine352 Mission ALALA71350713227135171369Provider TypeGeneral DentistGeneral DentistGeneral DentistGeneral DentistMedicaid AcceptiongPCD - Potential LOI orSTP Y/NSpecialty New Patients Age RestrictionLinkagesContractCodeY/N66666666yyyyNo restrictionsNo restrictionsNo restrictionsNo AvoyellesAvoyellesAvoyellesAvoyellesMarch 2013
Attachment F.1.A Proposed Provider Network ListingLast Name First Name actice Name/Provider NameBusiness AddressMerryville Community Health Center567 Walker StreetDental Plus1808 Hwy 190 West, Ste DDental Plus1808 Hwy 190 West, Ste DMerryville Community Health Center567 Walker StreetJames T Shirley307 S Washington StreetThomas H Shirley, DDS307 S Washington 063470634Provider TypeGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistAcceptiongMedicaidPCD - Potential LOI orSTP Y/NNew Patients Age RestrictionSpecialty CodeLinkagesContractY/N666666666666YyyYyyNo restrictionsAdults onlyAdults onlyNo restrictionsNo restrictionsNo regardBeauregardBeauregardMarch 2013
Attachment F.1.A Proposed Provider Network ListingLast NameFirst Name TitlePractice Name/Provider NameBusiness AddressCitySTZipProvider TypeMedicaidSpecialty CodeAcceptiong NewPatients Y/NAge RestrictionPCD - PotentialLinkagesLOI or ContractSTP Y/NParishMarch 2013
Attachment F.1.A Proposed Provider Network ListingLast monIniguezVandiverFirst Name rysolRichardDDSDDSDDSDDSDDSDDSDDSDDSDDSDDSPractice Name/Provider NameDavid Raines Community Health CenterDavid Raines Community Health CenterPaul M Clark DDSDavid K Clark, DDSDavid Raines Community Health CenterDavid Raines Community Health CenterDavid Raines Community Health CenterFrank W Harmon DDSOutreach DentistryDavid Raines Community Health CenterBusiness Address1514 Doctors Drive1514 Doctors Drive1525 Doctors Drive1525 Doctors Dr.1514 Doctors Drive1514 Doctors Drive1514 Doctors Drive1525 Doctors Dr.837 Windham Court1514 Doctors DriveCitySTZipProvider TypeBossier CityBossier CityBossier CityBossier CItyBossier CityBossier CityBossier CityBossier CityBossier CItyBossier 111171111711117111271111General DentistGeneral DentistOral SurgeryOral SurgeryGeneral DentistGeneral DentistGeneral DentistOral SurgeryGeneral DentistGeneral DentistMedicaid AcceptiongPCD - Potential LOI orSpecialty New Patients Age RestrictionSTP Y/N yyyyyyyyyNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo March 2013
Attachment F.1.A Proposed Provider Network ListingLast NameFirst Name TitlePractice Name/Provider NameBusiness AddressCitySTZipProvider TypeMedicaidSpecialty CodeAcceptiong NewPatients Y/NAge RestrictionPCD - PotentialLinkagesLOI or ContractSTP Y/NParishMarch 2013
Attachment F.1.A Proposed Provider Network ListingLast NameFirst PaulDavidDaisyDaisyMonicaDungDungKim ChiKim actice Name/Provider NameKool SmilesKool SmilesKool SmilesKool SmilesKool SmilesKool SmilesKool SmilesKool SmilesDavid Raines Community Health CenterDavid Raines Community Health CenterOutreach DentistryKool SmilesKool SmilesKool SmilesKool SmilesDavid Raines Community Health CenterDavid Raines Community Health CenterKool SmilesKool SmilesKool SmilesKool SmilesCasse Community Health InstitutePaul M Clark DDSDavid K Clark, DDSKool SmilesKool SmilesDavenport Family DentalKool SmilesKool SmilesKool SmilesKool SmilesKool SmilesKool SmilesDavid Raines Community Health CenterDavid Raines Community Health CenterDavid Raines Community Health CenterDavid Raines Community Health CenterKool SmilesKool SmilesKool SmilesKool SmilesDavid Raines Community Health CenterDavid Raines Community Health CenterKool SmilesKool SmilesKool SmilesKool SmilesKool SmilesBusiness Address3719 Jewella Avenue9018 Mansfield Road3719 Jewella Avenue9018 Mansfield Road3719 Jewella Avenue9018 Mansfield Road3719 Jewella Avenue9018 Mansfield Road12763 Lay Street1625 David Raines Road705 Wesley Avenue3719 Jewella Avenue9018 Mansfield Road3719 Jewella Avenue9018 Mansfield Road12763 Lay Street1625 David Raines Road3719 Jewella Avenue9018 Mansfield Road3719 Jewella Avenue9018 Mansfield Road2120 Bert Kouns Ind. Loop, Ste E2120 Bert Kouns , Ste D2120 Bert Kouns, Ste D3719 Jewella Avenue9018 Mansfield Road1850 Martin Luther King3719 Jewella Avenue9018 Mansfield Road3719 Jewella Avenue9018 Mansfield Road3719 Jewella Avenue9018 Mansfield Road12763 Lay Street1625 David Raines Road12763 Lay Street1625 David Raines Road3719 Jewella Avenue9018 Mansfield Road3719 Jewella Avenue9018 Mansfield Road12763 Lay Street1625 David Raines Road3719 Jewella Avenue9018 Mansfield Road3719 Jewella Avenue9018 Mansfield Road3719 Jewella LALALALALALALAProvider TypeGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistOral SurgeryOral SurgeryGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistOral SurgeryOral SurgeryGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistGeneral DentistMedicaid AcceptiongPCD - Potential LOI orSpecialty New Patients Age RestrictionSTP Y/N yyyyyyyyyyyyyyyyyyyyyyyNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsNo restrictionsN
Title: Practice Name/Provider Name. Business Address: City. ST: Zip. Provider Type: Medicaid Specialty Code. Acceptiong New Patients Y/N: Age Restriction. PCD - Potential
