Provider Demographics
NPI:1700137510
Name:NOVA DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:NOVA DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:NATHANIEL
Authorized Official - Last Name:VONDENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-235-3761
Mailing Address - Street 1:1602 W PINHOOK RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3735
Mailing Address - Country:US
Mailing Address - Phone:337-235-3761
Mailing Address - Fax:337-234-9327
Practice Address - Street 1:1602 W PINHOOK RD
Practice Address - Street 2:SUITE 303
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3735
Practice Address - Country:US
Practice Address - Phone:337-235-3761
Practice Address - Fax:337-234-9327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA59431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty