=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669071841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GIANCARLO BREZILLION DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2020
-----------------------------------------------------
Last Update Date | 02/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2517 NE 9TH AVE
-----------------------------------------------------
City | WILTON MANORS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33305-1284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-210-4376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 SE 2ND AVE APT 2017
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33131-2246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-306-8869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN28607
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------