Active NPI
Brett Irvin, DDS
- Dentist
- St Louis, IL
National Provider Identifier
1659417582
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- Practice address
- 1511 East Broadway
St Louis, IL 62201 - Phone
- (618) 482-3844
- Fax
- (618) 482-3843
- NPI assigned
- Jan 29, 2007
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | IL | Primary |
Addresses
Primary practice location
1511 East Broadway
St Louis, IL 62201
Mailing address
865 N 76TH E
St Louis, IL 62203
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1002311 | Medicaid | IL | |
| 101449 | Medicaid | IL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019025362 | IL | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1170028800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1659417582",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "865 N 76TH E",
"city": "ST LOUIS",
"state": "IL",
"postal_code": "62203"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1511 EAST BROADWAY",
"city": "ST LOUIS",
"state": "IL",
"postal_code": "62201",
"telephone_number": "618-482-3844",
"fax_number": "618-482-3843"
}
],
"practiceLocations": [],
"basic": {
"last_name": "IRVIN",
"first_name": "BRETT",
"name_prefix": "Mr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-01-29",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IL",
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1002311",
"state": "IL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "101449",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.