Provider Demographics
NPI:1407143456
Name:FLAHERTY, BRETT DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:DAVID
Last Name:FLAHERTY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N BEELINE HWY
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-3706
Mailing Address - Country:US
Mailing Address - Phone:928-474-4581
Mailing Address - Fax:928-474-4585
Practice Address - Street 1:712 N BEELINE HWY
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-3706
Practice Address - Country:US
Practice Address - Phone:928-474-4581
Practice Address - Fax:928-474-4585
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist