Healthcare Provider Details

I. General information

NPI: 1952167033
Provider Name (Legal Business Name): JOHN BROTHERS DDS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 06/01/2024
Certification Date: 06/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23441 MADISON ST STE 200
TORRANCE CA
90505-4756
US

IV. Provider business mailing address

23441 MADISON ST STE 200
TORRANCE CA
90505-4756
US

V. Phone/Fax

Practice location:
  • Phone: 206-465-8020
  • Fax:
Mailing address:
  • Phone: 206-465-8020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN BROTHERS
Title or Position: OWNER
Credential: DDS MD
Phone: 206-465-8020