Healthcare Provider Details

I. General information

NPI: 1659761765
Provider Name (Legal Business Name): BRANDON TRAMELL MACK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N 12TH ST SUITE 1105
TAMPA FL
33602-3661
US

IV. Provider business mailing address

1081 A1A BEACH BLVD
ST AUGUSTINE FL
32080-6733
US

V. Phone/Fax

Practice location:
  • Phone: 813-397-3632
  • Fax:
Mailing address:
  • Phone: 904-471-3291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN21070
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: