Provider Demographics
NPI:1679585392
Name:BRASUELL, TODD STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:STEPHEN
Last Name:BRASUELL
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 1:2332 COURS CARSON ST
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-6410
Mailing Address - Country:US
Mailing Address - Phone:985-674-1396
Mailing Address - Fax:
Practice Address - Street 1:71107 HIGHWAY 21
Practice Address - Street 2:SUITE 2
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7243
Practice Address - Country:US
Practice Address - Phone:985-892-5942
Practice Address - Fax:985-892-8996
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55501223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855502Medicaid