Healthcare Provider Details

I. General information

NPI: 1114461191
Provider Name (Legal Business Name): WESLEY BRIGNAC JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7205 HIGHWAY 74
SAINT GABRIEL LA
70776-4827
US

IV. Provider business mailing address

7205 HIGHWAY 74
SAINT GABRIEL LA
70776-4827
US

V. Phone/Fax

Practice location:
  • Phone: 225-319-2385
  • Fax:
Mailing address:
  • Phone: 225-319-2385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3932
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: