Provider Demographics
NPI:1659788057
Name:NELA DENTAL OF MONROE, LLC
Entity Type:Organization
Organization Name:NELA DENTAL OF MONROE, LLC
Other - Org Name:NELA DENTAL- MONROE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:VANCE
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-737-0964
Mailing Address - Street 1:2016 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5036
Mailing Address - Country:US
Mailing Address - Phone:318-387-5732
Mailing Address - Fax:
Practice Address - Street 1:2016 TOWER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5036
Practice Address - Country:US
Practice Address - Phone:318-387-5732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty