Provider Demographics
NPI:1194035352
Name:EXCEPTIONAL DENTAL OF KENNER
Entity Type:Organization
Organization Name:EXCEPTIONAL DENTAL OF KENNER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:BOURG
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-469-6333
Mailing Address - Street 1:1305 W ESPLANADE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2744
Mailing Address - Country:US
Mailing Address - Phone:504-469-6333
Mailing Address - Fax:504-469-6355
Practice Address - Street 1:1305 W ESPLANADE AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2744
Practice Address - Country:US
Practice Address - Phone:504-469-6333
Practice Address - Fax:504-469-6355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
LA5312261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty