Provider Demographics
NPI:1023732625
Name:DR. TODD S. BRASUELL LLC
Entity type:Organization
Organization Name:DR. TODD S. BRASUELL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARGIOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-892-5942
Mailing Address - Street 1:189 GREENBRIER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7297
Mailing Address - Country:US
Mailing Address - Phone:985-892-5942
Mailing Address - Fax:
Practice Address - Street 1:189 GREENBRIER BLVD STE A
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7297
Practice Address - Country:US
Practice Address - Phone:985-892-5942
Practice Address - Fax:985-892-8996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-28
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855502Medicaid