=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699209890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OWENS FAMILY DENTAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2017
-----------------------------------------------------
Last Update Date | 04/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 LONGVIEW DR SUITE 8
-----------------------------------------------------
City | DESTREHAN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70047-5077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-764-1615
-----------------------------------------------------
Fax | 985-764-1617
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 LONGVIEW DR SUITE 8
-----------------------------------------------------
City | DESTREHAN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70047-5077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-764-1615
-----------------------------------------------------
Fax | 985-764-1617
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RICHARD L OWENS
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 985-764-1615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3633
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------