1215239819 NPI number — J. BRENT GORRELL, DDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215239819 NPI number — J. BRENT GORRELL, DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J. BRENT GORRELL, DDS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215239819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
809 CUESTA DR
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
MOUNTAIN VIEW
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94040-3667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-967-1441
Provider Business Mailing Address Fax Number:
650-967-7341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 CUESTA DR
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
MOUNTAIN VIEW
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94040-3667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-967-1441
Provider Business Practice Location Address Fax Number:
650-967-7341
Provider Enumeration Date:
12/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GORRELL
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
BRENT
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
650-967-1441

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  28559 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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