Provider Demographics
NPI:1881968402
Name:NELA DENTAL OF FARMERVILLE, LLC
Entity type:Organization
Organization Name:NELA DENTAL OF FARMERVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-737-0965
Mailing Address - Street 1:7699 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:FARMERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71241-6165
Mailing Address - Country:US
Mailing Address - Phone:318-368-9518
Mailing Address - Fax:318-368-4480
Practice Address - Street 1:7699 HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:FARMERVILLE
Practice Address - State:LA
Practice Address - Zip Code:71241-6165
Practice Address - Country:US
Practice Address - Phone:318-368-9518
Practice Address - Fax:318-368-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA56301223G0001X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA26171Medicaid