MEDICARE: BRISBAIN R PUCAN PROFESSIONAL DENTAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1487749362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRISBAIN R PUCAN PROFESSIONAL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	2143 SPRINGS RD
Second Line	:	#51
City	:	VALLEJO
State	:	CA
Zip	:	94591-5566
Country	:	US
Telephone Number	:	707-552-3952
Fax Number	:	707-552-9320

Provider Business Practice Location Address
First Line	:	2143 SPRINGS RD
Second Line	:	#51
City	:	VALLEJO
State	:	CA
Zip	:	94591-5566
Country	:	US
Telephone Number	:	707-552-3952
Fax Number	:	707-552-9320

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. BRISBAIN RIGOR PUCAN
Credential	:	D.M.D
Telephone Number	:	707-552-3952

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/01/2008

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