Healthcare Provider Details

I. General information

NPI: 1396884862
Provider Name (Legal Business Name): RICHARD BRANSON BRINKER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435-A SE 8TH TERRACE
CAPE CORAL FL
33990
US

IV. Provider business mailing address

300 WOODSPATH RD
LIVERPOOL NY
13090-2840
US

V. Phone/Fax

Practice location:
  • Phone: 239-574-2000
  • Fax: 239-574-1144
Mailing address:
  • Phone: 315-458-3088
  • Fax: 315-458-5682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 19314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: