Healthcare Provider Details

I. General information

NPI: 1750363602
Provider Name (Legal Business Name): BRIAN BURKE BLATTER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2189 EAST ST
CONCORD CA
94520-2011
US

IV. Provider business mailing address

2189 EAST ST
CONCORD CA
94520-2011
US

V. Phone/Fax

Practice location:
  • Phone: 925-685-3175
  • Fax: 925-685-2695
Mailing address:
  • Phone: 925-685-3175
  • Fax: 925-685-2695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number39602
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: