Provider Demographics
NPI:1659437762
Name:BRUTUS, JEAN-DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEAN-DANIEL
Middle Name:
Last Name:BRUTUS
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 1:12300 KEMMERTON LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-2721
Mailing Address - Country:US
Mailing Address - Phone:301-262-1112
Mailing Address - Fax:301-262-2237
Practice Address - Street 1:12300 KEMMERTON LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-2721
Practice Address - Country:US
Practice Address - Phone:301-262-1112
Practice Address - Fax:301-262-2237
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD136731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4108761Medicaid