Provider Demographics
NPI:1275061079
Name:ELLIS D. BRAUD AND FRED A. TENNEY
Entity Type:Organization
Organization Name:ELLIS D. BRAUD AND FRED A. TENNEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BRAUD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-446-2888
Mailing Address - Street 1:810 BAYOU LN
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4906
Mailing Address - Country:US
Mailing Address - Phone:985-446-2888
Mailing Address - Fax:985-447-1007
Practice Address - Street 1:810 BAYOU LN
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4906
Practice Address - Country:US
Practice Address - Phone:985-446-2888
Practice Address - Fax:985-447-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA29633Medicaid
LA29215Medicaid