Provider Demographics
NPI:1073721981
Name:BRACCO, BRENT J (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:J
Last Name:BRACCO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2461 E COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4020
Mailing Address - Country:US
Mailing Address - Phone:954-771-5303
Mailing Address - Fax:954-771-2032
Practice Address - Street 1:2461 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4020
Practice Address - Country:US
Practice Address - Phone:954-771-5303
Practice Address - Fax:954-771-2032
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 10456122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist