Healthcare Provider Details

I. General information

NPI: 1164864336
Provider Name (Legal Business Name): BRANSON BRACES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 S. PAYNE STEWART DR. STE 100
BRANSON MO
65616
US

IV. Provider business mailing address

168 S PAYNE STEWART DR STE 100
BRANSON MO
65616
US

V. Phone/Fax

Practice location:
  • Phone: 417-335-4746
  • Fax:
Mailing address:
  • Phone: 417-335-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK DAKE
Title or Position: MEMBER
Credential: DDS, MSD
Phone: 417-256-5100