Provider Demographics
NPI:1306557871
Name:BRAZOS VALLEY DENTAL GROUP, LLC
Entity type:Organization
Organization Name:BRAZOS VALLEY DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-695-8000
Mailing Address - Street 1:219 ROCK PRAIRIE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8796
Mailing Address - Country:US
Mailing Address - Phone:979-695-8000
Mailing Address - Fax:979-314-9702
Practice Address - Street 1:219 ROCK PRAIRIE RD STE 100
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8796
Practice Address - Country:US
Practice Address - Phone:979-695-8000
Practice Address - Fax:979-314-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental