1972056638 NPI number — ROSS H. DIES, J. CODY COWEN, DDS, BENJAMIN A. BEACH, DDS AND BRYAN STE

Table of content: (NPI 1972056638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972056638 NPI number — ROSS H. DIES, J. CODY COWEN, DDS, BENJAMIN A. BEACH, DDS AND BRYAN STE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSS H. DIES, J. CODY COWEN, DDS, BENJAMIN A. BEACH, DDS AND BRYAN STE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHREVEPORT BOSSIER FAMILY DENTAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972056638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3412 BARKSDALE BLVD
Provider Second Line Business Mailing Address:
100
Provider Business Mailing Address City Name:
BOSSIER CITY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71112-3800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-686-7470
Provider Business Mailing Address Fax Number:
318-686-4505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3412 BARKSDALE BLVD
Provider Second Line Business Practice Location Address:
100
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71112-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-686-7470
Provider Business Practice Location Address Fax Number:
318-686-4505
Provider Enumeration Date:
07/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DIES
Authorized Official First Name:
ROSS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
318-213-4686

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  4273 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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