Provider Demographics
NPI:1194087742
Name:GREENWALT, BRANDON LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:LEE
Last Name:GREENWALT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-328-8371
Mailing Address - Fax:386-328-1519
Practice Address - Street 1:410 NE WALDO RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32641-5685
Practice Address - Country:US
Practice Address - Phone:352-375-3790
Practice Address - Fax:352-375-3791
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 19737122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist