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General NPI Number Information
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NPI Number | 1043645765
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Entity Type | Organization
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Legal Business Name | BRIVADENTAL LLC
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Dates
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Enumeration Date | 09/12/2013
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Last Update Date | 11/12/2020
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Provider Practice Location Address
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Address Line | 13695 N 75TH AVE
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City | PEORIA
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State | AZ
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Zip | 85381-6098
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Country | US
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Telephone | 602-439-1101
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Fax | 602-789-1653
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Provider Business Mailing Address
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Address Line | 13695 N 75TH AVE
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City | PEORIA
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State | AZ
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Zip | 85381-6098
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Country | US
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Telephone | 602-439-1101
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Fax | 602-789-1653
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Authorized Official
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Title or Position | OWNER
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Name | DR. VASUDHA NARRA
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Credential | DDS
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Telephone | 602-439-1101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | D07658
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License Number State | AZ
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