1396912564 NPI number — DR. BRIAN F VESTAL D.D.S.

Table of content: DR. BRIAN F VESTAL D.D.S. (NPI 1396912564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396912564 NPI number — DR. BRIAN F VESTAL D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VESTAL
Provider First Name:
BRIAN
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

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:
1396912564
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 PASADENA AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33707-1251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-347-1214
Provider Business Mailing Address Fax Number:
727-302-0401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 PASADENA AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33707-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-347-1214
Provider Business Practice Location Address Fax Number:
727-302-0401
Provider Enumeration Date:
05/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN 17713 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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