Provider Demographics
NPI:1437278496
Name:BRIZENDINE, STEVEN FARREL (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:FARREL
Last Name:BRIZENDINE
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S FAIRMONT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3860
Mailing Address - Country:US
Mailing Address - Phone:209-368-5101
Mailing Address - Fax:
Practice Address - Street 1:525 S FAIRMONT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3860
Practice Address - Country:US
Practice Address - Phone:209-368-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942168742OtherTAX ID