Provider Demographics
NPI:1417605742
Name:STAFFORD, BRANDON JOSEPH
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JOSEPH
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WALTER REMLEY DR
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-3350
Mailing Address - Country:US
Mailing Address - Phone:507-208-3987
Mailing Address - Fax:
Practice Address - Street 1:114 WALTER REMLEY DR
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3350
Practice Address - Country:US
Practice Address - Phone:765-267-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK76271223G0001X
390200000X
IN12013947A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program