Healthcare Provider Details

I. General information

NPI: 1649437286
Provider Name (Legal Business Name): SSC DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5436 COMMERCE ST
SAINT FRANCISVILLE LA
70775-2880
US

IV. Provider business mailing address

PO BOX 2880
SAINT FRANCISVILLE LA
70775-2880
US

V. Phone/Fax

Practice location:
  • Phone: 225-635-4422
  • Fax: 225-635-2171
Mailing address:
  • Phone: 225-635-4422
  • Fax: 225-635-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. FRANK V SULLIVAN
Title or Position: GENERAL DENTIST OWNER
Credential:
Phone: 225-635-4422