Provider Demographics
NPI:1083787014
Name:BREDA, LEONARD C III (DDS)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:C
Last Name:BREDA
Suffix:III
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 1:903 MILL ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-4437
Mailing Address - Country:US
Mailing Address - Phone:337-433-5545
Mailing Address - Fax:337-433-5527
Practice Address - Street 1:903 MILL ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-4437
Practice Address - Country:US
Practice Address - Phone:337-433-5545
Practice Address - Fax:337-433-5527
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1840513Medicaid
LA4051OtherDENTIST