Provider Demographics
NPI:1285704205
Name:BRANHAM, JEROME RAYMOND SR (DDS)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:RAYMOND
Last Name:BRANHAM
Suffix:SR
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 1:751 CHESTNUT ST
Mailing Address - Street 2:# 104
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009
Mailing Address - Country:US
Mailing Address - Phone:248-723-4566
Mailing Address - Fax:248-723-4546
Practice Address - Street 1:751 CHESTNUT ST
Practice Address - Street 2:# 104
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009
Practice Address - Country:US
Practice Address - Phone:248-723-4566
Practice Address - Fax:248-723-4546
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI138731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1549658Medicaid