Healthcare Provider Details

I. General information

NPI: 1578938148
Provider Name (Legal Business Name): PCP DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 MAGAZINE ST
NEW ORLEANS LA
70115-2734
US

IV. Provider business mailing address

4221 MAGAZINE ST
NEW ORLEANS LA
70115-2734
US

V. Phone/Fax

Practice location:
  • Phone: 504-304-4761
  • Fax: 504-302-2672
Mailing address:
  • Phone: 504-304-4761
  • Fax: 504-302-2672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6165
License Number StateLA

VIII. Authorized Official

Name: DR. PAUL PEREZ
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 504-304-4761