Provider Demographics
NPI:1023246121
Name:BRIGHAM AND BRIGHAM PROFESSIONAL
Entity type:Organization
Organization Name:BRIGHAM AND BRIGHAM PROFESSIONAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-742-9852
Mailing Address - Street 1:2281 BENTON RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3403
Mailing Address - Country:US
Mailing Address - Phone:318-742-9852
Mailing Address - Fax:
Practice Address - Street 1:2281 BENTON RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3403
Practice Address - Country:US
Practice Address - Phone:318-742-9852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4469122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty