Provider Demographics
NPI:1245494814
Name:LA DENTAL URGENT CARE LLC
Entity type:Organization
Organization Name:LA DENTAL URGENT CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER OF LLC/OWNER/PROVID
Authorized Official - Prefix:MISS
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBOUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-926-0702
Mailing Address - Street 1:3121 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065
Mailing Address - Country:US
Mailing Address - Phone:504-390-2847
Mailing Address - Fax:504-218-4204
Practice Address - Street 1:4021 W. E. HECK CT
Practice Address - Street 2:I-L
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816
Practice Address - Country:US
Practice Address - Phone:225-926-0702
Practice Address - Fax:504-218-4204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5635122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1880426Medicaid