Provider Demographics
NPI:1912034687
Name:BRAGDON, LA JUANA DELISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LA JUANA
Middle Name:DELISE
Last Name:BRAGDON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 SUNS UP WAY
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031
Mailing Address - Country:US
Mailing Address - Phone:314-830-2004
Mailing Address - Fax:
Practice Address - Street 1:565 HOWDERSHELL RD.
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031
Practice Address - Country:US
Practice Address - Phone:314-249-9975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015977122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO403864614Medicaid