Provider Demographics
NPI:1639340425
Name:MADZAREVIC, BRANISLAV (DDS)
Entity Type:Individual
Prefix:
First Name:BRANISLAV
Middle Name:
Last Name:MADZAREVIC
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 1:312 N GAFFEY ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731
Mailing Address - Country:US
Mailing Address - Phone:310-833-7348
Mailing Address - Fax:310-833-0697
Practice Address - Street 1:312 N GAFFEY ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731
Practice Address - Country:US
Practice Address - Phone:310-833-7348
Practice Address - Fax:310-833-0697
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31057122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist