Provider Demographics
NPI:1407043367
Name:BRAIN, GEORGE CALVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:CALVIN
Last Name:BRAIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 S UNION AVE
Mailing Address - Street 2:B-3008
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1702
Mailing Address - Country:US
Mailing Address - Phone:253-572-9777
Mailing Address - Fax:253-627-6766
Practice Address - Street 1:1901 S UNION AVE
Practice Address - Street 2:B-3008
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1702
Practice Address - Country:US
Practice Address - Phone:253-572-9777
Practice Address - Fax:253-627-6766
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000035511223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5031455Medicaid