Provider Demographics
NPI:1982180279
Name:EXCEPTIONAL DENTAL OF WATSON, LLC
Entity Type:Organization
Organization Name:EXCEPTIONAL DENTAL OF WATSON, LLC
Other - Org Name:EXCEPTIONAL DENTAL OF LOUISIANA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:INSURANCE CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:COATS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-609-2599
Mailing Address - Street 1:34659 LA HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70706-0667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34659 LA HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70706-0667
Practice Address - Country:US
Practice Address - Phone:504-232-6624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5312122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty