Provider Demographics
NPI:1679004188
Name:GREGORY J. BRANDAU D.D.S., PLLC
Entity type:Organization
Organization Name:GREGORY J. BRANDAU D.D.S., PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BRANDAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-265-1004
Mailing Address - Street 1:2762 TAMIAMI TRL
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5128
Mailing Address - Country:US
Mailing Address - Phone:941-629-4804
Mailing Address - Fax:941-629-7702
Practice Address - Street 1:2762 TAMIAMI TRL
Practice Address - Street 2:SUITE B
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5128
Practice Address - Country:US
Practice Address - Phone:941-629-4804
Practice Address - Fax:941-629-7702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-26
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-216271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty