Provider Demographics
NPI:1679976724
Name:BRAZIL, ANTHONY RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:RAY
Last Name:BRAZIL
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 1:554 KEILY STREET
Mailing Address - Street 2:BUREAU OF MED AND SURGERY, CENTRALIZED
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32312
Mailing Address - Country:US
Mailing Address - Phone:757-953-7011
Mailing Address - Fax:
Practice Address - Street 1:554 KEILY STREET
Practice Address - Street 2:BUREAU OF MED AND SURGERY, CENTRALIZED CRED AND PRIV
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32312
Practice Address - Country:US
Practice Address - Phone:757-953-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60494136122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist