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Organization
COUNTRY CLUB DENTAL
Active
Organization
COUNTRY CLUB DENTAL
Active
Other names
Louisiana Dental Spa
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DARRELL PAUL BOURG JR. DDS (DENTIST)
(504) 232-6624
Entity
Organization
Contact information
Practice address
16645 HIGHLAND RD STE J, BATON ROUGE, LA 70810-6567
(225) 214-0100
(225) 214-0103
Mailing address
16645 HIGHLAND RD STE J, BATON ROUGE, LA 70810-6567
(225) 214-0100
(225) 214-0103
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
5312
LA
Other
Enumeration date
12/20/2006
Last updated
08/22/2020
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