Provider Demographics
NPI:1154770733
Name:BRANDON GREENWALT DMD PLLC
Entity type:Organization
Organization Name:BRANDON GREENWALT DMD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GREENWALT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:317-408-5764
Mailing Address - Street 1:328 W KARI CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-3320
Mailing Address - Country:US
Mailing Address - Phone:317-408-5764
Mailing Address - Fax:
Practice Address - Street 1:12443 SAN JOSE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8647
Practice Address - Country:US
Practice Address - Phone:904-262-6188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN197371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty