MEDICARE: CENTRAL DENTAL CARE

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	5406	LA

General Provider Information

NPI Number	:	1609934488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL DENTAL CARE

Provider Business Mailing Address
First Line	:	11424 SULLIVAN ROAD BLDG B SUITE A
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70818
Country	:	US
Telephone Number	:	225-261-6645
Fax Number	:	225-262-9061

Provider Business Practice Location Address
First Line	:	11424 SULLIVAN RD BLDG B SUITE A
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70818-3615
Country	:	US
Telephone Number	:	225-261-6645
Fax Number	:	225-262-9061

Authorized Official
Title or Position	:	OWNER
Name	:	JACOB F HENDERSON
Credential	:	D.D.S.
Telephone Number	:	225-261-6645

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/14/2008

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