Provider Demographics
NPI:1699090365
Name:BOUTTE DENTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:BOUTTE DENTAL ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:LACOSTE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-345-0240
Mailing Address - Street 1:14243 US HIGHWAY 190
Mailing Address - Street 2:
Mailing Address - City:BOUTTE
Mailing Address - State:LA
Mailing Address - Zip Code:70039
Mailing Address - Country:US
Mailing Address - Phone:985-785-0488
Mailing Address - Fax:
Practice Address - Street 1:14243 US HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:BOUTTE
Practice Address - State:LA
Practice Address - Zip Code:70039
Practice Address - Country:US
Practice Address - Phone:985-785-0488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3427261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental