Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 26591 | CA |
NPI | 1003807199 |
---|---|
Provider Name | Dr. George W Brazeal |
First Address | Corona Del Mar, CA 92625-2034 |
Second Address | Corona Del Mar, CA 92625-2034 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/10/2005 |
Last Update Date | 07/08/2007 |