Provider Demographics
NPI:1386019909
Name:EXCEPTIONAL DENTAL OF MID CITY LLC
Entity type:Organization
Organization Name:EXCEPTIONAL DENTAL OF MID CITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:P
Authorized Official - Last Name:B
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-232-6624
Mailing Address - Street 1:4141 BIENVILLE ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-5149
Mailing Address - Country:US
Mailing Address - Phone:504-232-6624
Mailing Address - Fax:504-340-7207
Practice Address - Street 1:4141 BIENVILLE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5149
Practice Address - Country:US
Practice Address - Phone:504-232-6624
Practice Address - Fax:504-340-7207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty