Healthcare Provider Details

I. General information

NPI: 1649542028
Provider Name (Legal Business Name): CRESCENT CITY DENTISTRY ST. ROSE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10964 RIVER RD
SAINT ROSE LA
70087
US

IV. Provider business mailing address

8229 JEFFERSON HWY
HARAHAN LA
70123-4617
US

V. Phone/Fax

Practice location:
  • Phone: 504-486-9778
  • Fax:
Mailing address:
  • Phone: 504-739-9778
  • Fax: 504-739-9871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5373
License Number StateLA

VIII. Authorized Official

Name: DR. CLEOPATRA EYVONNE THOMPSON
Title or Position: CEO
Credential: D.D.S.
Phone: 504-486-9778