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General NPI Number Information
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NPI Number | 1154770733
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Entity Type | Organization
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Legal Business Name | BRANDON GREENWALT DMD PLLC
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Dates
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Enumeration Date | 06/06/2016
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Last Update Date | 06/06/2016
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Provider Practice Location Address
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Address Line | 12443 SAN JOSE BLVD STE 101
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City | JACKSONVILLE
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State | FL
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Zip | 32223-8647
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Country | US
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Telephone | 904-262-6188
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Fax |
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Provider Business Mailing Address
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Address Line | 328 W KARI CT
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City | JACKSONVILLE
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State | FL
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Zip | 32259-3320
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Country | US
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Telephone | 317-408-5764
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRANDON LEE GREENWALT
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Credential | DMD
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Telephone | 317-408-5764
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN19737
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License Number State | FL
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