Healthcare Provider Details

I. General information

NPI: 1679267116
Provider Name (Legal Business Name): GUNNER LANE BRANTLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 N RIDGEVIEW DR
WARRENSBURG MO
64093-9336
US

IV. Provider business mailing address

400 RIVERWALK TER STE 250
JENKS OK
74037-5619
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-9117
  • Fax:
Mailing address:
  • Phone: 918-998-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7910
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2024038491
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: