Provider Demographics
NPI:1477076727
Name:BARDELOZA, BRIAN BENASA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:BENASA
Last Name:BARDELOZA
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 1:14201 NE 20TH AVE STE B200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-6412
Mailing Address - Country:US
Mailing Address - Phone:360-571-8181
Mailing Address - Fax:360-573-4022
Practice Address - Street 1:605 SE 164TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-882-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD108171223G0001X
WADE608768851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice