Provider Demographics
NPI:1699072330
Name:BRIAN M. BIVENS, DMD, MS, PA
Entity type:Organization
Organization Name:BRIAN M. BIVENS, DMD, MS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-443-5050
Mailing Address - Street 1:12950 RACE TRACK RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1309
Mailing Address - Country:US
Mailing Address - Phone:813-443-5050
Mailing Address - Fax:813-749-7526
Practice Address - Street 1:12950 RACE TRACK RD
Practice Address - Street 2:SUITE 107
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1309
Practice Address - Country:US
Practice Address - Phone:813-443-5050
Practice Address - Fax:813-749-7526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223E0200X, 1223P0221X, 1223S0112X
FLDN62951223P0300X
FLDN166681223X0400X
FLDH15021124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty