Healthcare Provider Details

I. General information

NPI: 1013319102
Provider Name (Legal Business Name): BRANIMIR VATAVUK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 HOMER AVE
PALO ALTO CA
94301-2887
US

IV. Provider business mailing address

510 WHISPERING WIND DRIVE
TRACY CA
95377
US

V. Phone/Fax

Practice location:
  • Phone: 650-328-7333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63732
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: