Provider Demographics
NPI:1386031664
Name:FLORES SOUSA, BRENDA (DDS)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:FLORES SOUSA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6003 BIG TREE RD.
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14480
Mailing Address - Country:US
Mailing Address - Phone:585-346-3028
Mailing Address - Fax:585-756-5577
Practice Address - Street 1:6003 BIG TREE RD.
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:NY
Practice Address - Zip Code:14480
Practice Address - Country:US
Practice Address - Phone:585-346-3028
Practice Address - Fax:585-756-5577
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0590511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1467897009OtherNPI