Provider Demographics
NPI:1780609040
Name:BROWN, JERRY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:BROWN
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 1:181 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2801
Mailing Address - Country:US
Mailing Address - Phone:509-684-3736
Mailing Address - Fax:509-684-3407
Practice Address - Street 1:181 E 1ST AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2801
Practice Address - Country:US
Practice Address - Phone:509-684-3736
Practice Address - Fax:509-684-3407
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000105671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5050836Medicaid
WA0210275OtherLABOR & INDUSTRIES ID #