=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760568729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON MCKAY DEVER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 10/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4014 FOOTHILLS BLVD # 103
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95747-7233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-773-4343
-----------------------------------------------------
Fax | 916-773-4348
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2350 GRASS VALLEY HWY
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95603-2554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-823-2423
-----------------------------------------------------
Fax | 530-823-5580
-----------------------------------------------------
=====================================================
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 | 55641
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22021
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------