Provider Demographics
NPI:1215516737
Name:GERVASI, BRANDON
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:GERVASI
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 1:45 E LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OH
Mailing Address - Zip Code:44425-2160
Mailing Address - Country:US
Mailing Address - Phone:330-534-5408
Mailing Address - Fax:
Practice Address - Street 1:45 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:HUBBARD
Practice Address - State:OH
Practice Address - Zip Code:44425-2160
Practice Address - Country:US
Practice Address - Phone:330-534-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.026773122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program