Healthcare Provider Details

I. General information

NPI: 1235264367
Provider Name (Legal Business Name): BRETT D MADERE DDS APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CENTRAL AVENUE RESERVE LA
RESERVE LA
70084
US

IV. Provider business mailing address

190 CENTRAL AVENUE RESERVE LA PO DRAWER O RESERVE LA
RESERVE LA
70084
US

V. Phone/Fax

Practice location:
  • Phone: 985-536-3193
  • Fax:
Mailing address:
  • Phone: 985-536-3193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberLA 4435
License Number StateLA

VIII. Authorized Official

Name: DR. BRETT D MADERE
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 985-536-3193