Provider Demographics
NPI:1326102062
Name:DAIGLE, BRYAN PAUL
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:PAUL
Last Name:DAIGLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 MARTENS DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-1620
Mailing Address - Country:US
Mailing Address - Phone:985-345-4242
Mailing Address - Fax:
Practice Address - Street 1:1502 MARTENS DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-1620
Practice Address - Country:US
Practice Address - Phone:985-345-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4869122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist