Healthcare Provider Details

I. General information

NPI: 1962103028
Provider Name (Legal Business Name): BROOKE ELIZABETH NAQUIN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12519 AIRLINE HWY STE G
DESTREHAN LA
70047-2502
US

IV. Provider business mailing address

12519 AIRLINE HWY STE G
DESTREHAN LA
70047-2502
US

V. Phone/Fax

Practice location:
  • Phone: 985-764-7792
  • Fax:
Mailing address:
  • Phone: 985-764-7792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7438
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: