Provider Demographics
NPI:1952436404
Name:ST. BERNARD DENTAL GROUP
Entity Type:Organization
Organization Name:ST. BERNARD DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:CREAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-392-9874
Mailing Address - Street 1:2600 BELLE CHASSE HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7156
Mailing Address - Country:US
Mailing Address - Phone:504-392-9874
Mailing Address - Fax:504-392-9990
Practice Address - Street 1:2600 BELLE CHASSE HWY STE 200
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-7156
Practice Address - Country:US
Practice Address - Phone:504-392-9874
Practice Address - Fax:504-392-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1880311Medicaid