Provider Demographics
NPI:1285772301
Name:PAYNE, BRANDON C (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:C
Last Name:PAYNE
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4728 EAGLERIDGE CIR STE 110
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2196
Mailing Address - Country:US
Mailing Address - Phone:719-542-4546
Mailing Address - Fax:719-542-4548
Practice Address - Street 1:4728 EAGLERIDGE CIR STE 110
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2196
Practice Address - Country:US
Practice Address - Phone:719-542-4546
Practice Address - Fax:719-542-4548
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2024-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101361223S0112X
CO50000204E00000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33987220Medicaid