Healthcare Provider Details

I. General information

NPI: 1194806778
Provider Name (Legal Business Name): BRANDON ALLEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W BROAD ST
RICHMOND VA
23220-4219
US

IV. Provider business mailing address

300 W BROAD ST
RICHMOND VA
23220-4219
US

V. Phone/Fax

Practice location:
  • Phone: 804-780-2888
  • Fax: 804-643-1916
Mailing address:
  • Phone: 804-780-2888
  • Fax: 804-643-1916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401411279
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: