Healthcare Provider Details

I. General information

NPI: 1437986114
Provider Name (Legal Business Name): BRANDON DIETER CANAZA RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7115 GUILFORD DR STE 101
FREDERICK MD
21704-5234
US

IV. Provider business mailing address

6949 EXETER CT APT 103
FREDERICK MD
21703-6466
US

V. Phone/Fax

Practice location:
  • Phone: 240-379-1550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7557
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: