Healthcare Provider Details

I. General information

NPI: 1336879535
Provider Name (Legal Business Name): BRANDON R CANADAY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4873 BELLE TERRE PKWY
PALM COAST FL
32137-8696
US

IV. Provider business mailing address

6405 JACK WRIGHT ISLAND RD
SAINT AUGUSTINE FL
32092-1910
US

V. Phone/Fax

Practice location:
  • Phone: 386-864-8313
  • Fax:
Mailing address:
  • Phone: 904-521-3899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN27075
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: