Provider Demographics
NPI:1033271804
Name:BREAUX, JOHNNIE (DDS)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:
Last Name:BREAUX
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 BEHRMAN PL
Mailing Address - Street 2:SUITE Q
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-0950
Mailing Address - Country:US
Mailing Address - Phone:504-368-4555
Mailing Address - Fax:504-368-0006
Practice Address - Street 1:4021 BEHRMAN PL
Practice Address - Street 2:SUITE Q
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-0950
Practice Address - Country:US
Practice Address - Phone:504-368-4555
Practice Address - Fax:504-368-0006
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA44141223G0001X
TN46901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice