Provider Demographics
NPI:1003807199
Name:BRAZEAL, GEORGE W (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:W
Last Name:BRAZEAL
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 1:2345 E COAST HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2034
Mailing Address - Country:US
Mailing Address - Phone:949-673-6443
Mailing Address - Fax:
Practice Address - Street 1:2345 E COAST HWY
Practice Address - Street 2:SUITE B
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2034
Practice Address - Country:US
Practice Address - Phone:949-673-6443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-29
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26591122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist