=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831348051
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRANHAM DENTAL ARTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2008
-----------------------------------------------------
Last Update Date | 06/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23700 ORCHARD LAKE RD STE A
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48336-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-474-5572
-----------------------------------------------------
Fax | 248-474-3039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23700 ORCHARD LAKE RD STE A
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48336-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-474-5572
-----------------------------------------------------
Fax | 248-474-3039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KIMBERLY L BRANHAM
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 248-474-5572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901019601
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------