Provider Demographics
NPI:1043499643
Name:BRISCO, STEPHEN CRAIG (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CRAIG
Last Name:BRISCO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:STEPHEN
Other - Middle Name:C
Other - Last Name:BRISCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1100 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-2714
Mailing Address - Country:US
Mailing Address - Phone:504-619-8721
Mailing Address - Fax:
Practice Address - Street 1:1100 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-2714
Practice Address - Country:US
Practice Address - Phone:504-619-8721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA41651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1841650Medicaid