Provider Demographics
NPI:1235394610
Name:BOGALUSA DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:BOGALUSA DENTAL ASSOCIATES, LLC
Other - Org Name:LOUISIANA DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:LACOSTE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-735-0078
Mailing Address - Street 1:218 MEMPHIS ST
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3844
Mailing Address - Country:US
Mailing Address - Phone:985-735-0078
Mailing Address - Fax:
Practice Address - Street 1:218 MEMPHIS ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3844
Practice Address - Country:US
Practice Address - Phone:985-735-0078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3427122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty