Provider Demographics
NPI:1912163395
Name:BROWN, BRIAN (DMD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:570-253-8226
Mailing Address - Fax:570-253-8228
Practice Address - Street 1:58 8TH AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-2297
Practice Address - Country:US
Practice Address - Phone:570-282-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037541122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist