Provider Demographics
NPI:1134345184
Name:COSMETIC DENTISTRY OF BATON ROUGE, LLC
Entity type:Organization
Organization Name:COSMETIC DENTISTRY OF BATON ROUGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:VENTRESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-926-8954
Mailing Address - Street 1:632 SHADOWS LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6532
Mailing Address - Country:US
Mailing Address - Phone:225-926-8954
Mailing Address - Fax:225-927-4055
Practice Address - Street 1:632 SHADOWS LN
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6532
Practice Address - Country:US
Practice Address - Phone:225-926-8954
Practice Address - Fax:225-927-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA51471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty