Provider Demographics
NPI: | 1811361314 |
---|---|
Name: | ZACHARY DENTAL ASSOCIATES, LLC |
Entity Type: | Organization |
Organization Name: | ZACHARY DENTAL ASSOCIATES, LLC |
Other - Org Name: | LOUISIANA DENTAL CENTER |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOSEPH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LACOSTE |
Authorized Official - Suffix: | JR |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 985-893-2240 |
Mailing Address - Street 1: | 600 N HIGHWAY 190 |
Mailing Address - Street 2: | SUITE 200 |
Mailing Address - City: | COVINGTON |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 70433-5003 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1081 COPPERMILL BLVD. |
Practice Address - Street 2: | |
Practice Address - City: | ZACHARY |
Practice Address - State: | LA |
Practice Address - Zip Code: | 70791 |
Practice Address - Country: | US |
Practice Address - Phone: | 985-893-2240 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-11-20 |
Last Update Date: | 2015-11-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
LA | 3427 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Multi-Specialty |