MEDICARE: MR. BRETT IRVIN DDS

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	122300000X	Dentist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659417582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRETT IRVIN DDS

Provider Business Mailing Address
First Line	:	865 N 76TH E
Second Line	:
City	:	ST LOUIS
State	:	IL
Zip	:	62203
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1511 EAST BROADWAY
Second Line	:
City	:	ST LOUIS
State	:	IL
Zip	:	62201
Country	:	US
Telephone Number	:	618-482-3844
Fax Number	:	618-482-3843

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/08/2007

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Directions to “ MR. BRETT IRVIN DDS” Practice Location

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