Provider Demographics
NPI:1598060642
Name:OPELOUSAS DENTAL LLC
Entity Type:Organization
Organization Name:OPELOUSAS DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIDGETTE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:VIDRINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-942-3441
Mailing Address - Street 1:506 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-5220
Mailing Address - Country:US
Mailing Address - Phone:337-942-3441
Mailing Address - Fax:337-942-3461
Practice Address - Street 1:506 N COURT ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-5220
Practice Address - Country:US
Practice Address - Phone:337-942-3441
Practice Address - Fax:337-942-3461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA58851223G0001X
LA60401223G0001X
124Q00000X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty