Provider Demographics
NPI:1003970682
Name:COUNTRY CLUB DENTAL
Entity Type:Organization
Organization Name:COUNTRY CLUB DENTAL
Other - Org Name:LOUISIANA DENTAL SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BOURG
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-232-6624
Mailing Address - Street 1:16645 HIGHLAND RD STE J
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-6567
Mailing Address - Country:US
Mailing Address - Phone:225-214-0100
Mailing Address - Fax:225-214-0103
Practice Address - Street 1:16645 HIGHLAND RD STE J
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-6567
Practice Address - Country:US
Practice Address - Phone:225-214-0100
Practice Address - Fax:225-214-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1783521Medicare UPIN