Provider Demographics
NPI:1184706509
Name:DANIELSSON, BRIAN LORY (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LORY
Last Name:DANIELSSON
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 1:700 N SANDERS ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3528
Mailing Address - Country:US
Mailing Address - Phone:760-371-4800
Mailing Address - Fax:760-371-4825
Practice Address - Street 1:700 N SANDERS ST
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3528
Practice Address - Country:US
Practice Address - Phone:760-371-4800
Practice Address - Fax:760-371-4825
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA352431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice