Provider Demographics
NPI:1083743454
Name:BRANNEN, JOHN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:BRANNEN
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 1:111 LAKEWOOD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070-3002
Mailing Address - Country:US
Mailing Address - Phone:985-785-6838
Mailing Address - Fax:
Practice Address - Street 1:111 LAKEWOOD DR
Practice Address - Street 2:SUITE A
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-3002
Practice Address - Country:US
Practice Address - Phone:985-785-6838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA39311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAA1998LAOtherBC-BS OF LA
LA1839311Medicaid
TN4017984TNOtherBC-BS OF TN