Healthcare Provider Details

I. General information

NPI: 1215516737
Provider Name (Legal Business Name): DR. BRANDON GERVASI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 E LIBERTY ST
HUBBARD OH
44425-2160
US

IV. Provider business mailing address

45 E LIBERTY ST
HUBBARD OH
44425-2160
US

V. Phone/Fax

Practice location:
  • Phone: 330-534-5408
  • Fax:
Mailing address:
  • Phone: 330-534-5408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.026773
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: