Healthcare Provider Details

I. General information

NPI: 1790984714
Provider Name (Legal Business Name): BRANCH DENTAL CLINIC FUTENMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 482
FPO AP
96362
US

IV. Provider business mailing address

PSC 482
FPO AP
96362
US

V. Phone/Fax

Practice location:
  • Phone: 011816117432014
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM M CONDON
Title or Position: BUMED UBO
Credential:
Phone: 240-401-3643