MEDICARE: BRAZEAL DENTAL CORPORATION

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	1223G0001X	General Practice Dentistry	54954	CA

General Provider Information

NPI Number	:	1306187935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAZEAL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	5948 WARNER AVE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-4660
Country	:	US
Telephone Number	:	714-846-1414
Fax Number	:	714-846-8181

Provider Business Practice Location Address
First Line	:	5948 WARNER AVE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-4660
Country	:	US
Telephone Number	:	714-846-1414
Fax Number	:	714-846-8181

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRETT C BRAZEAL
Credential	:	DDS
Telephone Number	:	310-795-0585

Provider Enumeration Date	:	03/06/2013
Last Update Date	:	03/06/2013

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