Provider Demographics
NPI:1831258623
Name:MUDD, BRIAN DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:MUDD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1544 MISSION MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-4803
Mailing Address - Country:US
Mailing Address - Phone:760-945-9011
Mailing Address - Fax:760-945-9172
Practice Address - Street 1:3909 WARING RD
Practice Address - Street 2:#D
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4455
Practice Address - Country:US
Practice Address - Phone:760-945-9011
Practice Address - Fax:760-945-9172
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT70436Medicare UPIN