Provider Demographics
NPI:1144230079
Name:AVRA, BRET A (D,MD)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:A
Last Name:AVRA
Suffix:
Gender:M
Credentials:D,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 KENTUCKY AVE
Mailing Address - Street 2:STE #302
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-443-1717
Mailing Address - Fax:270-443-0517
Practice Address - Street 1:2605 KENTUCKY AVE
Practice Address - Street 2:STE #302
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3800
Practice Address - Country:US
Practice Address - Phone:270-443-1717
Practice Address - Fax:270-443-0517
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY62831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY37-1469385OtherTAX ID
KY560132OtherUNITED CONCORDIA
KYX98145Medicare UPIN