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General NPI Number Information
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NPI Number | 1003815655
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Entity Type | Individual
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Provider Name | RANDY JAMES BREEN D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 07/17/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 515 LAKESIDE DR SE #208
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-2931
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Country | US
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Telephone | 616-454-9091
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Fax | 616-454-1159
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Provider Business Mailing Address
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Address Line | 2435 ROLLING MEADOW DR NE
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City | BELMONT
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State | MI
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Zip | 49306-9332
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Country | US
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Telephone | 616-863-9515
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901014055
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License Number State | MI
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