Provider Demographics
NPI:1184270159
Name:REBOTTARO, BRANDON WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:WILLIAM
Last Name:REBOTTARO
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 1:720 CAMINO RAMON STE 150
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4261
Mailing Address - Country:US
Mailing Address - Phone:925-837-1464
Mailing Address - Fax:
Practice Address - Street 1:720 CAMINO RAMON STE 150
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4261
Practice Address - Country:US
Practice Address - Phone:925-837-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA1051861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program