Healthcare Provider Details

I. General information

NPI: 1225209562
Provider Name (Legal Business Name): BRANDON HULL D.M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 FEATHERSTONE RD STE. B
ROCKFORD IL
61107-5904
US

IV. Provider business mailing address

1055 FEATHERSTONE RD STE. B
ROCKFORD IL
61107-5904
US

V. Phone/Fax

Practice location:
  • Phone: 815-227-5858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019027462
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021002370
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: