Healthcare Provider Details

I. General information

NPI: 1770681256
Provider Name (Legal Business Name): BRANDON LUTHER NASH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5345 N EL DORADO ST SUITE 1
STOCKTON CA
95207-5872
US

IV. Provider business mailing address

5345 N EL DORADO ST SUITE 1
STOCKTON CA
95207-5872
US

V. Phone/Fax

Practice location:
  • Phone: 209-952-1561
  • Fax: 209-952-2962
Mailing address:
  • Phone: 209-952-1561
  • Fax: 209-952-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number46413
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: