=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700137510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA DENTAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2012
-----------------------------------------------------
Last Update Date | 09/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1602 W PINHOOK RD SUITE 303
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70508-3735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-235-3761
-----------------------------------------------------
Fax | 337-234-9327
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1602 W PINHOOK RD SUITE 303
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70508-3735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-235-3761
-----------------------------------------------------
Fax | 337-234-9327
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ERIC NATHANIEL VONDENSTEIN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 337-235-3761
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5943
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------