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General NPI Number Information
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NPI Number | 1306844667
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Entity Type | Individual
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Provider Name | BRIAN LEE SECRIST D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 07/11/2005
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Last Update Date | 10/24/2024
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Provider Practice Location Address
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Address Line | 1900 E MAIN ST
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City | DANVILLE
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State | IL
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Zip | 61832-5100
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Country | US
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Telephone | 217-554-5859
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Fax |
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Provider Business Mailing Address
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Address Line | 24206 MATEO RDG
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City | SAN ANTONIO
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State | TX
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Zip | 78261-4504
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Country | US
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Telephone | 303-859-6016
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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 | 105294
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License Number State | CO
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