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General NPI Number Information
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NPI Number | 1225338593
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Entity Type | Organization
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Legal Business Name | OAK GROVE DENTAL
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Dates
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Enumeration Date | 11/02/2010
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Last Update Date | 11/02/2010
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Provider Practice Location Address
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Address Line | 414 ROSS ST
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City | OAK GROVE
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State | LA
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Zip | 71263-9727
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Country | US
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Telephone | 318-428-4255
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 390
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City | OAK GROVE
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State | LA
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Zip | 71263-0390
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Country | US
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Telephone | 318-428-4255
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Fax |
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Authorized Official
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Title or Position | CO OWNER
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Name | DR. ROBERT VANCE COSTELLO
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Credential | DDS
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Telephone | 318-428-4255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5630
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License Number State | LA
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