Provider Demographics
NPI:1548094436
Name:BRAVO DENTAL CORPORATION
Entity type:Organization
Organization Name:BRAVO DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-635-0892
Mailing Address - Street 1:215 N STATE COLLEGE BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-2934
Mailing Address - Country:US
Mailing Address - Phone:714-635-0892
Mailing Address - Fax:
Practice Address - Street 1:215 N STATE COLLEGE BLVD STE E
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2934
Practice Address - Country:US
Practice Address - Phone:714-635-0892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental