Provider Demographics
NPI:1679267116
Name:BRANTLEY, GUNNER LANE (DDS)
Entity type:Individual
Prefix:DR
First Name:GUNNER
Middle Name:LANE
Last Name:BRANTLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:
Practice Address - Street 1:511 N RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-9336
Practice Address - Country:US
Practice Address - Phone:660-747-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE79101223G0001X
MO20240384911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice