Provider Demographics
NPI:1467577130
Name:DISTINCTIVE SMILES OF BATON ROUGE, LLC
Entity Type:Organization
Organization Name:DISTINCTIVE SMILES OF BATON ROUGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANCERIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'ROURKE -ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-218-9218
Mailing Address - Street 1:8894 AIRLINE HWY
Mailing Address - Street 2:SUITE M
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-4081
Mailing Address - Country:US
Mailing Address - Phone:225-218-9218
Mailing Address - Fax:225-218-9219
Practice Address - Street 1:8894 AIRLINE HWY
Practice Address - Street 2:SUITE M
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-4081
Practice Address - Country:US
Practice Address - Phone:225-218-9218
Practice Address - Fax:225-218-9219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA51311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1851311Medicaid