Provider Demographics
NPI:1336880913
Name:BULLOCH, BRANDON SCOTT (DDS)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:SCOTT
Last Name:BULLOCH
Suffix:
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 1:3394 N FUTRALL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3937
Mailing Address - Country:US
Mailing Address - Phone:479-582-3360
Mailing Address - Fax:
Practice Address - Street 1:3394 N FUTRALL DR STE 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3937
Practice Address - Country:US
Practice Address - Phone:479-582-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR47951223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics