Provider Demographics
NPI:1184839169
Name:BRANSON, BRENDA LACY (DMD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LACY
Last Name:BRANSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 N EASTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-3831
Mailing Address - Country:US
Mailing Address - Phone:215-887-0122
Mailing Address - Fax:215-887-0122
Practice Address - Street 1:856 N EASTON RD
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-3831
Practice Address - Country:US
Practice Address - Phone:215-887-0122
Practice Address - Fax:215-887-0122
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026465L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice