MEDICARE: DISTINCTIVE SMILES OF BATON ROUGE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5131	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467577130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DISTINCTIVE SMILES OF BATON ROUGE, LLC

Provider Business Mailing Address
First Line	:	8894 AIRLINE HWY
Second Line	:	SUITE M
City	:	BATON ROUGE
State	:	LA
Zip	:	70815-4081
Country	:	US
Telephone Number	:	225-218-9218
Fax Number	:	225-218-9219

Provider Business Practice Location Address
First Line	:	8894 AIRLINE HWY
Second Line	:	SUITE M
City	:	BATON ROUGE
State	:	LA
Zip	:	70815-4081
Country	:	US
Telephone Number	:	225-218-9218
Fax Number	:	225-218-9219

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SANCERIE J O'ROURKE -ALLEN
Credential	:
Telephone Number	:	225-218-9218

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	12/09/2009

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