Provider Demographics
NPI:1760511893
Name:LEY, BRIAN C (DDS, PC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:LEY
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10097
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0020
Mailing Address - Country:US
Mailing Address - Phone:520-836-3446
Mailing Address - Fax:
Practice Address - Street 1:865 N ARIZOLA RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6011
Practice Address - Country:US
Practice Address - Phone:520-836-3446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO79761223G0001X
AZ10642122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22125001Medicaid