Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 34754 | CA |
NPI | 1023013398 |
---|---|
Provider Name | Dr. Brian William Payne |
First Address | Santa Rosa, CA 95405-6615 |
Second Address | Santa Rosa, CA 95405-6615 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2005 |
Last Update Date | 08/07/2007 |