Provider Demographics
NPI:1972008332
Name:BROUILLETTE, ANDREW JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOSEPH
Last Name:BROUILLETTE
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 1:4956 OLD OAK DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-9366
Mailing Address - Country:US
Mailing Address - Phone:318-458-0478
Mailing Address - Fax:
Practice Address - Street 1:385 BERT KOUNS INDUSTRIAL LOOP STE 700
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-524-7729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA68431223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA008580874OtherDRIVER'S LICENSE