Provider Demographics
NPI:1154687770
Name:BRANDNER, JOSHUA STEPHEN (DDS, MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:STEPHEN
Last Name:BRANDNER
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 248977
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73124-8977
Mailing Address - Country:US
Mailing Address - Phone:877-667-7669
Mailing Address - Fax:888-920-7457
Practice Address - Street 1:363 LAKEVIEW CT
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7515
Practice Address - Country:US
Practice Address - Phone:985-687-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60732399204E00000X
390200000X
LA62651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2304810Medicaid