Provider Demographics
NPI:1750531208
Name:DAUPHIN, BRENT (LAC)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:DAUPHIN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 ANCHORAGE AVE
Mailing Address - Street 2:APT B
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-5417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 ANCHORAGE AVE
Practice Address - Street 2:APT B
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-5417
Practice Address - Country:US
Practice Address - Phone:415-577-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-21
Last Update Date:2008-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12647171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist