=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114736774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND FAMILY DENTISTRY ABITA SPRINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2025
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22464 LA HWY 435
-----------------------------------------------------
City | ABITA SPRINGS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70420-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-893-7835
-----------------------------------------------------
Fax | 985-778-0301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 ASBURY DR
-----------------------------------------------------
City | MANDEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70471-1844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-778-0096
-----------------------------------------------------
Fax | 985-778-0301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTANT
-----------------------------------------------------
Name | MARY COTTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 985-778-0096
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------