Provider Demographics
NPI:1972056638
Name:ROSS H. DIES, J. CODY COWEN, DDS, BENJAMIN A. BEACH, DDS AND BRYAN STE
Entity Type:Organization
Organization Name:ROSS H. DIES, J. CODY COWEN, DDS, BENJAMIN A. BEACH, DDS AND BRYAN STE
Other - Org Name:SHREVEPORT BOSSIER FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-213-4686
Mailing Address - Street 1:3412 BARKSDALE BLVD
Mailing Address - Street 2:100
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-3800
Mailing Address - Country:US
Mailing Address - Phone:318-686-7470
Mailing Address - Fax:318-686-4505
Practice Address - Street 1:3412 BARKSDALE BLVD
Practice Address - Street 2:100
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-3800
Practice Address - Country:US
Practice Address - Phone:318-686-7470
Practice Address - Fax:318-686-4505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA42731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty