Provider Demographics
NPI:1710361118
Name:EXCEPTIONAL DENTAL
Entity Type:Organization
Organization Name:EXCEPTIONAL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-433-2092
Mailing Address - Street 1:27136 HIGHWAY 23
Mailing Address - Street 2:SUITE 314
Mailing Address - City:PORT SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70083-2648
Mailing Address - Country:US
Mailing Address - Phone:504-433-2092
Mailing Address - Fax:
Practice Address - Street 1:27136 HIGHWAY 23
Practice Address - Street 2:SUITE 314
Practice Address - City:PORT SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70083-2648
Practice Address - Country:US
Practice Address - Phone:504-433-2092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty