MEDICARE: DR. GREGORY JAMES BRANDAU DDS

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	30-024328	OH
2	1223G0001X	General Practice Dentistry	DN-21627	FL

General Provider Information

NPI Number	:	1750784955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY JAMES BRANDAU DDS

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2014
Last Update Date	:	03/26/2017

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