MEDICARE: BURTON BRENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	G26091	CA

General Provider Information

NPI Number	:	1073915039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BURTON BRENT

Provider Business Mailing Address
First Line	:	2995 WOODSIDE RD STE 400
Second Line	:
City	:	WOODSIDE
State	:	CA
Zip	:	94062-2448
Country	:	US
Telephone Number	:	650-851-5300
Fax Number	:	650-851-5302

Provider Business Practice Location Address
First Line	:	341 GROVE DR
Second Line	:
City	:	PORTOLA VALLEY
State	:	CA
Zip	:	94028-7642
Country	:	US
Telephone Number	:	650-851-5300
Fax Number	:	650-851-5302

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2014
Last Update Date	:	09/22/2014

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Directions to “ BURTON BRENT ” Practice Location

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