=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750563342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILLIP MARVIN BRAME DDS MS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2007
-----------------------------------------------------
Last Update Date | 12/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1419 WEST D ST
-----------------------------------------------------
City | NORTH WILKESBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28659-1367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-667-1254
-----------------------------------------------------
Fax | 336-667-1255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1367 1419 WEST D ST
-----------------------------------------------------
City | NORTH WILKESBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28659-1367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-667-1254
-----------------------------------------------------
Fax | 336-667-1255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD CERTIFIED ORTHODONTIST
-----------------------------------------------------
Name | DR. PHILLIP MARVIN BRAME SR.
-----------------------------------------------------
Credential | DDS MS
-----------------------------------------------------
Telephone | 336-667-1254
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 3987
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------