Provider Demographics
NPI:1659417582
Name:IRVIN, BRETT (DDS)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:
Last Name:IRVIN
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 1:865 N 76TH E
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1511 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201
Practice Address - Country:US
Practice Address - Phone:618-482-3844
Practice Address - Fax:618-482-3843
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002311Medicaid
IL101449Medicaid