Healthcare Provider Details

I. General information

NPI: 1053066167
Provider Name (Legal Business Name): WEST BRAZOS DENTAL CENTER BRAZORIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 N BROOKS ST
BRAZORIA TX
77422-8718
US

IV. Provider business mailing address

PO BOX 5005
BRAZORIA TX
77422-5005
US

V. Phone/Fax

Practice location:
  • Phone: 979-248-4248
  • Fax: 979-798-9109
Mailing address:
  • Phone: 979-798-9103
  • Fax: 979-798-9109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIM R YEAROUT
Title or Position: OFFICE MANAGER
Credential:
Phone: 979-345-1023