Provider Demographics
NPI:1477975175
Name:LONN E BRANDER DDS LTD
Entity type:Organization
Organization Name:LONN E BRANDER DDS LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LONN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BRANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-756-2295
Mailing Address - Street 1:5668 E STATE ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2490
Mailing Address - Country:US
Mailing Address - Phone:815-977-5281
Mailing Address - Fax:815-977-5361
Practice Address - Street 1:5668 E STATE ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2490
Practice Address - Country:US
Practice Address - Phone:815-977-5281
Practice Address - Fax:815-977-5361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
IL019-022322122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7032150002Medicare NSC