Healthcare Provider Details

I. General information

NPI: 1003654492
Provider Name (Legal Business Name): COLLIN C. BRANT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N ASHLAND AVE
CHICAGO IL
60622-5111
US

IV. Provider business mailing address

901 N ASHLAND AVE
CHICAGO IL
60622-5111
US

V. Phone/Fax

Practice location:
  • Phone: 773-546-9126
  • Fax:
Mailing address:
  • Phone: 773-546-9126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.035413
License Number StateIL
# 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: