| Organization Name: | COUNTRY CLUB DENTAL |
| NPI Number: | 1003970682 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DARRELL PAUL BOURG (DENTIST) |
| Mailing Address: | 16645 Highland Rd Ste J Baton Rouge |
| State: | LA US |
| Postal Code: | 708106567 |
| Phone Number: | 2252140100 |
| Fax Number: | 2252140103 |
| NPI Enumeration Date: | 12/20/2006 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223G0001X |
| License Number: | 5312 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | LA |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | General Practice |
| Taxonomy Definition: | A general dentist is the primary dental care provider for patients of all ages. The general dentist is responsible for the diagnosis, treatment, management and overall coordination of services related to patients' oral health needs. |