Healthcare Provider Details

I. General information

NPI: 1194035352
Provider Name (Legal Business Name): EXCEPTIONAL DENTAL OF KENNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 W ESPLANADE AVE
KENNER LA
70065-2744
US

IV. Provider business mailing address

1305 W ESPLANADE AVE
KENNER LA
70065-2744
US

V. Phone/Fax

Practice location:
  • Phone: 504-469-6333
  • Fax: 504-469-6355
Mailing address:
  • Phone: 504-469-6333
  • Fax: 504-469-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5312
License Number StateLA

VIII. Authorized Official

Name: DR. DARRELL PHILIP BOURG JR.
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 504-469-6333