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General NPI Number Information
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NPI Number | 1174771463
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Entity Type | Organization
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Legal Business Name | COLLINS BLVD FAMILY DENTISTRY
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Dates
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Enumeration Date | 08/29/2008
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Last Update Date | 08/29/2008
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Provider Practice Location Address
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Address Line | 842 N. COLLINS BLVD SUITE F
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City | COVINGTON
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State | LA
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Zip | 70433-2759
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Country | US
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Telephone | 985-809-1889
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Fax | 985-809-9553
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Provider Business Mailing Address
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Address Line | 842 N COLLINS BLVD SUITE F
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City | COVINGTON
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State | LA
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Zip | 70433-2759
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Country | US
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Telephone | 985-809-1889
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Fax | 985-809-9553
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Authorized Official
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Title or Position | DENTIST
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Name | DR. SUSANNE O CORE
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Credential | DMD
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Telephone | 985-809-1889
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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