Healthcare Provider Details

I. General information

NPI: 1629038708
Provider Name (Legal Business Name): JOHN BRANDEBURA JR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2407 S WALDRON RD
FORT SMITH AR
72903-3736
US

IV. Provider business mailing address

2407 S WALDRON RD
FORT SMITH AR
72903-3736
US

V. Phone/Fax

Practice location:
  • Phone: 479-484-1011
  • Fax: 479-484-1205
Mailing address:
  • Phone: 479-484-1011
  • Fax: 479-484-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2226
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: