Provider Demographics
NPI:1740344225
Name:DARRELL P. BOURG JR. DDS
Entity type:Organization
Organization Name:DARRELL P. BOURG JR. DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BOURG
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-340-9696
Mailing Address - Street 1:21 SAN CARLOS AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2240
Mailing Address - Country:US
Mailing Address - Phone:504-621-6338
Mailing Address - Fax:504-340-7207
Practice Address - Street 1:2521 AMES BLVD STE C
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-5154
Practice Address - Country:US
Practice Address - Phone:504-340-9696
Practice Address - Fax:504-340-7207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA57471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1337710Medicare UPIN