Provider Demographics
NPI:1760511893
Name:LEY, BRIAN C (DDS, PC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:LEY
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 W ORANGE GROVE RD BLDG 2
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1193
Mailing Address - Country:US
Mailing Address - Phone:520-797-8030
Mailing Address - Fax:
Practice Address - Street 1:1751 W ORANGE GROVE RD BLDG 2
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1193
Practice Address - Country:US
Practice Address - Phone:520-797-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO79761223G0001X
AZ10642122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22125001Medicaid