Healthcare Provider Details

I. General information

NPI: 1023013398
Provider Name (Legal Business Name): BRIAN WILLIAM PAYNE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 DOCTORS PARK DR
SANTA ROSA CA
95405-6615
US

IV. Provider business mailing address

36 DOCTORS PARK DR
SANTA ROSA CA
95405-6615
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-5234
  • Fax: 707-546-3928
Mailing address:
  • Phone: 707-546-5234
  • Fax: 707-546-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number34754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: