Provider Demographics
NPI:1477702330
Name:POTTER, BRETT RUSSELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:RUSSELL
Last Name:POTTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2351
Mailing Address - Country:US
Mailing Address - Phone:361-576-1235
Mailing Address - Fax:361-573-4113
Practice Address - Street 1:103 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2351
Practice Address - Country:US
Practice Address - Phone:361-576-1235
Practice Address - Fax:361-573-4113
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX283411223E0200X
WADE600314361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223E0200XDental ProvidersDentistEndodontics