Provider Demographics
NPI:1831326529
Name:KING, BREANNA MARIE (DMD)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11160 BLACKWATER DRAW STREET
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89179
Mailing Address - Country:US
Mailing Address - Phone:702-496-4587
Mailing Address - Fax:
Practice Address - Street 1:9285 S CIMARRON RD STE 125
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89178
Practice Address - Country:US
Practice Address - Phone:702-433-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV58091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice