Provider Demographics
NPI:1174771463
Name:COLLINS BLVD FAMILY DENTISTRY
Entity type:Organization
Organization Name:COLLINS BLVD FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:O
Authorized Official - Last Name:CORE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:985-809-1889
Mailing Address - Street 1:842 N COLLINS BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-2759
Mailing Address - Country:US
Mailing Address - Phone:985-809-1889
Mailing Address - Fax:985-809-9553
Practice Address - Street 1:842 N. COLLINS BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2759
Practice Address - Country:US
Practice Address - Phone:985-809-1889
Practice Address - Fax:985-809-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty