MEDICARE: DR. MARK D BRANNON DDS

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	1223G0001X	General Practice Dentistry	D02856	AZ

General Provider Information

NPI Number	:	1942377569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK D BRANNON DDS

Provider Business Mailing Address
First Line	:	11110 N TATUM BLVD STE H102
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-1607
Country	:	US
Telephone Number	:	602-354-7607
Fax Number	:	602-354-7609

Provider Business Practice Location Address
First Line	:	11110 N TATUM BLVD STE H102
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-1607
Country	:	US
Telephone Number	:	602-354-7607
Fax Number	:	602-354-7609

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	04/09/2020

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