Provider Demographics
NPI:1861652935
Name:UDALL, BROOK MALAN (DDS)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:MALAN
Last Name:UDALL
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 1:10100 INDIAN HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9301
Mailing Address - Country:US
Mailing Address - Phone:916-663-1959
Mailing Address - Fax:
Practice Address - Street 1:13620 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-3261
Practice Address - Country:US
Practice Address - Phone:530-823-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA438731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice