Healthcare Provider Details

I. General information

NPI: 1487207510
Provider Name (Legal Business Name): BRANDON REYES COLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 RIVER RD STE 140
NORCO CA
92860-2402
US

IV. Provider business mailing address

7049 RIVERSIDE DR
CHINO CA
91710-9011
US

V. Phone/Fax

Practice location:
  • Phone: 951-225-1783
  • Fax:
Mailing address:
  • Phone: 951-283-2246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA90918
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: