Provider Demographics
NPI:1679836860
Name:MARK D BRANNON DDS LLC
Entity type:Organization
Organization Name:MARK D BRANNON DDS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-563-0000
Mailing Address - Street 1:21809 N SCOTTSDALE RD
Mailing Address - Street 2:C 105
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-7440
Mailing Address - Country:US
Mailing Address - Phone:480-563-0000
Mailing Address - Fax:480-563-4445
Practice Address - Street 1:21809 N SCOTTSDALE RD
Practice Address - Street 2:C 105
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-7440
Practice Address - Country:US
Practice Address - Phone:480-563-0000
Practice Address - Fax:480-563-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty