Healthcare Provider Details

I. General information

NPI: 1790993376
Provider Name (Legal Business Name): BRANDON C. PAYNE D.D.S., M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 11/10/2024
Certification Date: 11/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4728 EAGLERIDGE CIR STE 110
PUEBLO CO
81008-2196
US

IV. Provider business mailing address

4728 EAGLERIDGE CIR STE 110
PUEBLO CO
81008-2196
US

V. Phone/Fax

Practice location:
  • Phone: 719-542-4546
  • Fax: 719-542-4548
Mailing address:
  • Phone: 719-542-4546
  • Fax: 719-542-4548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10136
License Number StateCO

VIII. Authorized Official

Name: BRANDON C PAYNE
Title or Position: PRESIDENT
Credential: MD, DDS
Phone: 719-542-4546