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General NPI Number Information
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NPI Number | 1194035352
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Entity Type | Organization
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Legal Business Name | EXCEPTIONAL DENTAL OF KENNER
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Dates
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Enumeration Date | 10/20/2010
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Last Update Date | 12/08/2015
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Provider Practice Location Address
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Address Line | 1305 W ESPLANADE AVE
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City | KENNER
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State | LA
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Zip | 70065-2744
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Country | US
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Telephone | 504-469-6333
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Fax | 504-469-6355
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Provider Business Mailing Address
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Address Line | 1305 W ESPLANADE AVE
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City | KENNER
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State | LA
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Zip | 70065-2744
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Country | US
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Telephone | 504-469-6333
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Fax | 504-469-6355
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. DARRELL PHILIP BOURG JR.
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Credential | DDS
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Telephone | 504-469-6333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 5312
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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