Healthcare Provider Details

I. General information

NPI: 1477975175
Provider Name (Legal Business Name): LONN E BRANDER DDS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5668 E STATE ST SUITE 1100
ROCKFORD IL
61108-2490
US

IV. Provider business mailing address

5668 E STATE ST SUITE 1100
ROCKFORD IL
61108-2490
US

V. Phone/Fax

Practice location:
  • Phone: 815-977-5281
  • Fax: 815-977-5361
Mailing address:
  • Phone: 815-977-5281
  • Fax: 815-977-5361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-022322
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. LONN EDWARD BRANDER
Title or Position: OWNER
Credential: DDS
Phone: 815-756-2295