Provider Demographics
NPI:1801012018
Name:BREAUX, CARL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:J
Last Name:BREAUX
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 1:300 BERTRAND DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-5635
Mailing Address - Country:US
Mailing Address - Phone:337-261-0214
Mailing Address - Fax:337-235-3550
Practice Address - Street 1:300 BERTRAND DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5635
Practice Address - Country:US
Practice Address - Phone:337-261-0214
Practice Address - Fax:337-235-3550
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA37611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1837610Medicaid
LA1801012018OtherDEPARTMENT OF VETERANS AFFAIRS