Provider Demographics
NPI:1235544404
Name:BRANTLEY, DAVID WILLIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIS
Last Name:BRANTLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:WILL
Other - Middle Name:
Other - Last Name:BRANTLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:495 FURYS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-8221
Mailing Address - Country:US
Mailing Address - Phone:706-825-6196
Mailing Address - Fax:
Practice Address - Street 1:495 FURYS FERRY RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-8221
Practice Address - Country:US
Practice Address - Phone:706-825-6196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0147951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice