Provider Demographics
NPI:1326622515
Name:BRUSH DENTAL DOMAIN PC
Entity Type:Organization
Organization Name:BRUSH DENTAL DOMAIN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:862-216-8108
Mailing Address - Street 1:501 WEST AVE APT 1004
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-2899
Mailing Address - Country:US
Mailing Address - Phone:862-216-8108
Mailing Address - Fax:
Practice Address - Street 1:201 W 5TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2983
Practice Address - Country:US
Practice Address - Phone:512-713-1099
Practice Address - Fax:512-713-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty