Provider Demographics
NPI:1790390888
Name:PEARL DENTAL GROUP LLC
Entity Type:Organization
Organization Name:PEARL DENTAL GROUP LLC
Other - Org Name:PEARL DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRUNI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-256-1163
Mailing Address - Street 1:11001 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-4306
Mailing Address - Country:US
Mailing Address - Phone:225-256-1163
Mailing Address - Fax:225-351-8859
Practice Address - Street 1:6031 JONES CREEK RD.
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817
Practice Address - Country:US
Practice Address - Phone:225-256-1163
Practice Address - Fax:225-351-8859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-15
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1053523233OtherNPI
LA1639381890OtherNPI