Provider Demographics
NPI:1578904827
Name:DOCTORS DENTAL 05, LLC
Entity Type:Organization
Organization Name:DOCTORS DENTAL 05, LLC
Other - Org Name:DOCTORS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-768-4520
Mailing Address - Street 1:601 RIVER HIGHLAND BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8987
Mailing Address - Country:US
Mailing Address - Phone:985-768-4520
Mailing Address - Fax:985-310-7414
Practice Address - Street 1:7278 HIGHLAND RD
Practice Address - Street 2:SUITE C
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-6607
Practice Address - Country:US
Practice Address - Phone:225-329-1140
Practice Address - Fax:225-329-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5713261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental