MEDICARE: DR. VAN ALFRED BROLLINI 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	19331	CA

General Provider Information

NPI Number	:	1942374004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VAN ALFRED BROLLINI DDS

Provider Business Mailing Address
First Line	:	4118 WEST POINT LOMA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110
Country	:	US
Telephone Number	:	619-225-9354
Fax Number	:	619-225-8365

Provider Business Practice Location Address
First Line	:	4118 WEST POINT LOMA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110
Country	:	US
Telephone Number	:	619-225-9354
Fax Number	:	619-225-8365

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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