MEDICARE: GREGORY J. BRANDAU D.D.S., PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN-21627	FL

General Provider Information

NPI Number	:	1679004188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREGORY J. BRANDAU D.D.S., PLLC

Provider Business Mailing Address
First Line	:	2762 TAMIAMI TRL
Second Line	:	SUITE B
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5128
Country	:	US
Telephone Number	:	941-629-4804
Fax Number	:	941-629-7702

Provider Business Practice Location Address
First Line	:	2762 TAMIAMI TRL
Second Line	:	SUITE B
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5128
Country	:	US
Telephone Number	:	941-629-4804
Fax Number	:	941-629-7702

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. GREGORY JAMES BRANDAU
Credential	:	D.D.S.
Telephone Number	:	330-265-1004

Provider Enumeration Date	:	03/26/2017
Last Update Date	:	03/26/2017

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