MEDICARE: COUNTRY CLUB DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5312	LA

General Provider Information

NPI Number	:	1003970682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY CLUB DENTAL

Provider Business Mailing Address
First Line	:	16645 HIGHLAND RD STE J
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70810-6567
Country	:	US
Telephone Number	:	225-214-0100
Fax Number	:	225-214-0103

Provider Business Practice Location Address
First Line	:	16645 HIGHLAND RD STE J
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70810-6567
Country	:	US
Telephone Number	:	225-214-0100
Fax Number	:	225-214-0103

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. DARRELL PAUL BOURG JR.
Credential	:	DDS
Telephone Number	:	504-232-6624

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	08/22/2020

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Directions to “COUNTRY CLUB DENTAL ” Practice Location

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