Provider Demographics
NPI:1609871094
Name:DORFMAN, BRIAN J (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:DORFMAN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42104 N VENTURE DR
Mailing Address - Street 2:STE A106
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3824
Mailing Address - Country:US
Mailing Address - Phone:623-551-6556
Mailing Address - Fax:623-551-6557
Practice Address - Street 1:42104 N VENTURE DR
Practice Address - Street 2:STE A106
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3824
Practice Address - Country:US
Practice Address - Phone:623-551-6556
Practice Address - Fax:623-551-6557
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63371223S0112X
AZ32232204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZI34015Medicare UPIN