Provider Demographics
NPI:1649542028
Name:CRESCENT CITY DENTISTRY ST. ROSE, L.L.C.
Entity type:Organization
Organization Name:CRESCENT CITY DENTISTRY ST. ROSE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEOPATRA
Authorized Official - Middle Name:EYVONNE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-486-9778
Mailing Address - Street 1:8229 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:HARAHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70123-4617
Mailing Address - Country:US
Mailing Address - Phone:504-739-9778
Mailing Address - Fax:504-739-9871
Practice Address - Street 1:10964 RIVER RD
Practice Address - Street 2:
Practice Address - City:SAINT ROSE
Practice Address - State:LA
Practice Address - Zip Code:70087
Practice Address - Country:US
Practice Address - Phone:504-486-9778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty