Provider Demographics
NPI:1073352043
Name:DONATIEN, BREANNA
Entity type:Individual
Prefix:MISS
First Name:BREANNA
Middle Name:
Last Name:DONATIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28129 PEACOCK RIDGE DR APT 214
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-3441
Mailing Address - Country:US
Mailing Address - Phone:310-757-9399
Mailing Address - Fax:
Practice Address - Street 1:520 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3116
Practice Address - Country:US
Practice Address - Phone:310-832-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34010124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist