MEDICARE: MARY J. BRANNOCK DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	4818	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1992874689	OTHER	AZ	DENTAL

General Provider Information

NPI Number	:	1548456924
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY J. BRANNOCK DDS PC

Provider Business Mailing Address
First Line	:	13430 N SCOTTSDALE RD
Second Line	:	#100
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85254-4057
Country	:	US
Telephone Number	:	480-922-0600
Fax Number	:	480-922-0981

Provider Business Practice Location Address
First Line	:	13430 N SCOTTSDALE RD
Second Line	:	#100
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85254-4057
Country	:	US
Telephone Number	:	480-922-0600
Fax Number	:	480-922-0981

Authorized Official
Title or Position	:	OFICE MANAGER
Name	:	DAVID W BRANNOCK
Credential	:
Telephone Number	:	480-922-0600

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	09/19/2007

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