Provider Demographics
NPI:1972648186
Name:ELM STREET DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:ELM STREET DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BASHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-377-9411
Mailing Address - Street 1:909 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-2747
Mailing Address - Country:US
Mailing Address - Phone:318-377-9411
Mailing Address - Fax:318-377-1424
Practice Address - Street 1:909 ELM ST
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-2747
Practice Address - Country:US
Practice Address - Phone:318-377-9411
Practice Address - Fax:318-377-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty