MEDICARE: EXCEPTIONAL 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		LA

General Provider Information

NPI Number	:	1710361118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCEPTIONAL DENTAL

Provider Business Mailing Address
First Line	:	27136 HIGHWAY 23
Second Line	:	SUITE 314
City	:	PORT SULPHUR
State	:	LA
Zip	:	70083-2648
Country	:	US
Telephone Number	:	504-433-2092
Fax Number	:

Provider Business Practice Location Address
First Line	:	27136 HIGHWAY 23
Second Line	:	SUITE 314
City	:	PORT SULPHUR
State	:	LA
Zip	:	70083-2648
Country	:	US
Telephone Number	:	504-433-2092
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MIKE COOK
Credential	:
Telephone Number	:	504-433-2092

Provider Enumeration Date	:	07/15/2015
Last Update Date	:	07/15/2015

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Directions to “EXCEPTIONAL DENTAL ” Practice Location

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