Healthcare Provider Details

I. General information

NPI: 1255123261
Provider Name (Legal Business Name): BRANDON TIEN MAI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 28037
APO AE
09112-8037
US

IV. Provider business mailing address

PSC 445 BOX 657
APO AE
09046-0007
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2491
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14223194-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: