=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730712357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL TECHNOLOGY TRAINERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2020
-----------------------------------------------------
Last Update Date | 03/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 CALLE DEL ARROYO
-----------------------------------------------------
City | PLACITAS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87043-9407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-683-0817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 489 N L ST
-----------------------------------------------------
City | LIVERMORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94551-8005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-447-8344
-----------------------------------------------------
Fax | 925-447-4074
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROBERT BRANDES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 925-683-0817
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------