Provider Demographics
NPI:1194098723
Name:POTOCKI, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:POTOCKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 N TELSHOR BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3751 N MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-0300
Practice Address - Country:US
Practice Address - Phone:517-281-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020710122300000X
NMDD41661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist