Provider Demographics
NPI:1285759720
Name:BRANDON, MICHAEL STEPHEN JR (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:BRANDON
Suffix:JR
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:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-882-3974
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:3301 BERRYWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6517
Practice Address - Country:US
Practice Address - Phone:573-884-6253
Practice Address - Fax:573-875-9150
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4281122300000X
MO20170170861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4281Medicaid
VAV07319Medicare UPIN