=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003272907
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIVONA AND BRANSTETTER FAMILY DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2016
-----------------------------------------------------
Last Update Date | 01/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1208 HIGHWAY 78 E
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35501-3963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-221-2733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1208 HIGHWAY 78 E
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35501-3963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-221-2733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. JOHN BRANSTETTER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 205-221-2733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 4217
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------