Healthcare Provider Details

I. General information

NPI: 1154667210
Provider Name (Legal Business Name): BAYOU SMILES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 VICTOR II BLVD
MORGAN CITY LA
70380
US

IV. Provider business mailing address

1205 VICTOR II BLVD
MORGAN CITY LA
70380
US

V. Phone/Fax

Practice location:
  • Phone: 337-367-1721
  • Fax: 337-365-5137
Mailing address:
  • Phone: 337-367-1271
  • Fax: 337-365-5137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6019
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH P BRAUD JR.
Title or Position: OWNER
Credential: MSPH, DDS
Phone: 337-367-1271