Healthcare Provider Details

I. General information

NPI: 1568632016
Provider Name (Legal Business Name): BRIAN L GREY D.D.S., M.S.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 9TH ST
LAKEPORT CA
95453-4320
US

IV. Provider business mailing address

120 9TH ST
LAKEPORT CA
95453-4320
US

V. Phone/Fax

Practice location:
  • Phone: 707-263-5390
  • Fax: 707-263-9269
Mailing address:
  • Phone: 707-263-5390
  • Fax: 707-263-9269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number37557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: