Provider Demographics
NPI:1215239819
Name:J. BRENT GORRELL, DDS
Entity type:Organization
Organization Name:J. BRENT GORRELL, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:GORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-967-1441
Mailing Address - Street 1:809 CUESTA DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-3667
Mailing Address - Country:US
Mailing Address - Phone:650-967-1441
Mailing Address - Fax:650-967-7341
Practice Address - Street 1:809 CUESTA DR
Practice Address - Street 2:SUITE 205
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-3667
Practice Address - Country:US
Practice Address - Phone:650-967-1441
Practice Address - Fax:650-967-7341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28559261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental