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General NPI Number Information
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NPI Number | 1194098723
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Entity Type | Individual
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Provider Name | BRIAN POTOCKI
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Gender | Male
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Dates
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Enumeration Date | 02/13/2012
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Last Update Date | 09/05/2014
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Provider Practice Location Address
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Address Line | 3751 N MAIN ST SUITE D
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City | ROSWELL
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State | NM
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Zip | 88201-0300
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Country | US
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Telephone | 517-281-4747
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Fax |
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Provider Business Mailing Address
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Address Line | 530 N TELSHOR BLVD SUITE B
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City | LAS CRUCES
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State | NM
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Zip | 88011-8243
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Country | US
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Telephone |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901020710
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DD4166
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License Number State | NM
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