Provider Demographics
NPI:1568089837
Name:DAVEREDE HART, BRIELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIELLE
Middle Name:
Last Name:DAVEREDE HART
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:ORANGE BEACH
Mailing Address - State:AL
Mailing Address - Zip Code:36561-4003
Mailing Address - Country:US
Mailing Address - Phone:504-228-2978
Mailing Address - Fax:
Practice Address - Street 1:815 N ALSTON ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-3509
Practice Address - Country:US
Practice Address - Phone:251-943-8547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD00067711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice