Provider Demographics
NPI:1780825273
Name:BURKHALTER, BREAH E
Entity Type:Individual
Prefix:
First Name:BREAH
Middle Name:E
Last Name:BURKHALTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8894 AIRLINE HWY
Mailing Address - Street 2:SUITE M
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-4081
Mailing Address - Country:US
Mailing Address - Phone:225-218-9218
Mailing Address - Fax:
Practice Address - Street 1:8894 AIRLINE HWY
Practice Address - Street 2:SUITE M
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-4081
Practice Address - Country:US
Practice Address - Phone:225-218-9218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-13
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1860018Medicaid