Provider Demographics
NPI:1679766554
Name:BRITTON, WILLIAM REVIE, KENNETH
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:REVIE, KENNETH
Last Name:BRITTON
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 1:6148 PASEO GRANITO
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-2274
Mailing Address - Country:US
Mailing Address - Phone:562-832-2489
Mailing Address - Fax:858-566-6528
Practice Address - Street 1:9292 MIRA MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4806
Practice Address - Country:US
Practice Address - Phone:858-566-4200
Practice Address - Fax:858-566-6528
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56035122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD56035Medicaid