MEDICARE: BLUEBONNET DENTAL CARE @ MILLBROOK

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	122300000X	Dentist

General Provider Information

NPI Number	:	1528311768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBONNET DENTAL CARE @ MILLBROOK

Provider Business Mailing Address
First Line	:	4210 HIGHWAY 14
Second Line	:
City	:	MILLBROOK
State	:	AL
Zip	:	36054-1951
Country	:	US
Telephone Number	:	225-767-2273
Fax Number	:	225-769-3395

Provider Business Practice Location Address
First Line	:	4451 BLUEBONNET BLVD
Second Line	:	STE F
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-9646
Country	:	US
Telephone Number	:	225-767-2273
Fax Number	:	225-769-3395

Authorized Official
Title or Position	:	INSURANCE MANAGER
Name	:	JULIE JARREAU
Credential	:
Telephone Number	:	225-767-2273

Provider Enumeration Date	:	10/25/2012
Last Update Date	:	10/25/2012

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