Provider Demographics
NPI:1932123692
Name:TALLEY, BRIAN C (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:TALLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1970 E 3RD AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5025
Mailing Address - Country:US
Mailing Address - Phone:970-375-0110
Mailing Address - Fax:970-375-0111
Practice Address - Street 1:UTE MOUNTAIN UTE HEALTH CENTER DENTAL CLINIC
Practice Address - Street 2:232 RUSTLING WILLOW STREET
Practice Address - City:TOWAOC
Practice Address - State:CO
Practice Address - Zip Code:81334
Practice Address - Country:US
Practice Address - Phone:970-565-4441
Practice Address - Fax:970-565-4784
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS3223-021223P0221X
CO97281223P0221X
NC92761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90953614Medicaid