Provider Demographics
NPI:1669836656
Name:BRUSH DENTAL DOMAIN PC
Entity Type:Organization
Organization Name:BRUSH DENTAL DOMAIN PC
Other - Org Name:FLOSS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:862-216-8108
Mailing Address - Street 1:3310 W BRAKER LN
Mailing Address - Street 2:BLDG 1 SUITE 100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-7853
Mailing Address - Country:US
Mailing Address - Phone:512-617-0110
Mailing Address - Fax:
Practice Address - Street 1:3310 W BRAKER LN
Practice Address - Street 2:BLDG 1 SUITE 100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-7853
Practice Address - Country:US
Practice Address - Phone:512-617-0110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty