=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861915480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIELLE LYNN LIRA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2017
-----------------------------------------------------
Last Update Date | 03/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 E CAMP MOHAVE RD # 1
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86426-9406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-758-8887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2209 E VIA DEL AQUA DR
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86426-7033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-645-7306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D009815
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------