MEDICARE: CHILDRENS DENTAL CARE LLC

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	1223P0221X	Pediatric Dentistry	3507	LA

General Provider Information

NPI Number	:	1164677233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDRENS DENTAL CARE LLC

Provider Business Mailing Address
First Line	:	541 SHADOWS LN
Second Line	:	SUITE B
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-6531
Country	:	US
Telephone Number	:	225-924-2010
Fax Number	:	225-926-5872

Provider Business Practice Location Address
First Line	:	541 SHADOWS LN
Second Line	:	SUITE B
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-6531
Country	:	US
Telephone Number	:	225-924-2010
Fax Number	:	225-926-5872

Authorized Official
Title or Position	:	OWNER/ PRESIDENT
Name	:	DR. JEFF DOUGLAS ELLARD
Credential	:	DDS
Telephone Number	:	225-924-2010

Provider Enumeration Date	:	11/17/2008
Last Update Date	:	11/17/2008

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