Provider Demographics
NPI:1962597542
Name:CRESCENT CITY DENTISTRY, LLC
Entity type:Organization
Organization Name:CRESCENT CITY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEOPATRA
Authorized Official - Middle Name:EYVONNE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-739-9778
Mailing Address - Street 1:8229 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:HARAHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70123
Mailing Address - Country:US
Mailing Address - Phone:504-739-9778
Mailing Address - Fax:504-739-9871
Practice Address - Street 1:8229 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:HARAHAN
Practice Address - State:LA
Practice Address - Zip Code:70123
Practice Address - Country:US
Practice Address - Phone:504-739-9778
Practice Address - Fax:504-739-9871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1853739Medicaid