Healthcare Provider Details

I. General information

NPI: 1245294875
Provider Name (Legal Business Name): VICTOR DOUGLAS BROWN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 NILES HILL ROAD
COUDERSPORT PA
16915
US

IV. Provider business mailing address

1489 SR 49 EAST
COUDERSPORT PA
16915
US

V. Phone/Fax

Practice location:
  • Phone: 814-274-1111
  • Fax: 814-274-7786
Mailing address:
  • Phone: 814-274-7194
  • Fax: 814-274-7786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS022313L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: