Healthcare Provider Details

I. General information

NPI: 1629519590
Provider Name (Legal Business Name): ROSS BRENNER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 W UNIVERSITY AVE
GEORGETOWN TX
78628-5313
US

IV. Provider business mailing address

325 UNIVERSITY BLVD
ROUND ROCK TX
78665-1045
US

V. Phone/Fax

Practice location:
  • Phone: 317-289-1809
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number34682
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: