=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588482236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCEPTIONAL DENTAL OF CENTRAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2024
-----------------------------------------------------
Last Update Date | 10/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16606 GREENWELL SPRINGS RD
-----------------------------------------------------
City | GREENWELL SPRINGS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70739-4128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-262-4150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16606 GREENWELL SPRINGS RD
-----------------------------------------------------
City | GREENWELL SPRINGS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70739-4128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-262-4150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE CREDENTIALING MANAGER
-----------------------------------------------------
Name | MRS. SAMANTHA COATS
-----------------------------------------------------
Credential | CREDENTIALS
-----------------------------------------------------
Telephone | 504-609-2599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------