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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