Healthcare Provider Details

I. General information

NPI: 1861650004
Provider Name (Legal Business Name): RICHARD SCOTT BRAVERMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 E WALNUT AVE SUITE A
DALTON GA
30721-4552
US

IV. Provider business mailing address

2107 E WALNUT AVE.
DALTON GA
30721
US

V. Phone/Fax

Practice location:
  • Phone: 706-428-0235
  • Fax:
Mailing address:
  • Phone: 706-428-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10878
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: