Provider Demographics
NPI:1720380728
Name:BRANDON TREVINO, DDS, PA
Entity Type:Organization
Organization Name:BRANDON TREVINO, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-282-3411
Mailing Address - Street 1:1550 NORWOOD DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3646
Mailing Address - Country:US
Mailing Address - Phone:817-282-3411
Mailing Address - Fax:817-268-3529
Practice Address - Street 1:1550 NORWOOD DR
Practice Address - Street 2:SUITE 400
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3646
Practice Address - Country:US
Practice Address - Phone:817-282-3411
Practice Address - Fax:817-268-3529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX232641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189848820Medicaid