Healthcare Provider Details

I. General information

NPI: 1477076727
Provider Name (Legal Business Name): BRIAN BENASA BARDELOZA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 SE 164TH AVE STE 103
VANCOUVER WA
98684
US

IV. Provider business mailing address

14201 NE 20TH AVE STE B200
VANCOUVER WA
98686-6412
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-0222
  • Fax:
Mailing address:
  • Phone: 360-571-8181
  • Fax: 360-573-4022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10817
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60876885
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: