Provider Demographics
NPI:1073717799
Name:BRANNAN, CLARA WINONA (DDS)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:WINONA
Last Name:BRANNAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13002 106TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-3011
Mailing Address - Country:US
Mailing Address - Phone:253-209-7555
Mailing Address - Fax:
Practice Address - Street 1:719 SLEATER KINNEY RD SE
Practice Address - Street 2:SUITE 130
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1147
Practice Address - Country:US
Practice Address - Phone:360-455-1231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000109811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice